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.