We should be careful to get our of an experience only the wisdom that is in it - and stop there; lest we be like the cat that sits down on a ho stove-lid. She will never sit down on a hot stove-lid again, and that is well; but also she will never sit down on a cold one any more.Mark Twain
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I was recently told that ‘the problem’ underlying my often strained relationship with the institution where I work is that I am a revolutionary working in an institution committed to incrementalism.
Forty four good years, with more to come. I’ll honor it with some words we started with…
I don’t consider myself a laborer, though I surely work very hard. I work because I love to.
‘Taking a history’ is one of the first clinical tasks medical students are taught. The logic behind this is inescapable: without the history, attempts at diagnosis and treatment are doomed to failure. We start our training with the history, when we present patients for discussion with other doctors (in training or later, in practice) we start with the history. And except in rare emergencies, we start every patient interaction with the history. The history: it always starts there but it doesn’t end there.
The appointment was for his annual physical, and to review his well controlled hypertension and gout. After we had addressed these issues, I asked if there was anything else he was concerned about.
In a previous post I talked about some important questions I ask myself in my attempt to avoid missing the correct diagnosis.
I have a serious problem with the ubiquitous use of 'due' when talking with patients about what their medical options are. This came up recently when I was given a list of my patients who were ‘due’ for certain services, required if my institution is to receive a financial quality incentive. Typically, ‘due’ shows up in EHR alerts (the diabetic patient is 'due' for their A1c or microalbumin) and quality programs (patients are 'due' for a mammogram every 2 years, a DXA at 65, a pneumovax at 65, even well child visits at set intervals). Clinicians see it and hear it so often, it becomes part of our internal thought process. But it is wrong and harmful.
Treating patients with chronic pain is one of the more challenging tasks in primary care: how to measure pain, how to quantify disability and quality of life, how to balance to benefits of pain relief with the potential risks of medication, that it is usually multifactorial rather than simple, how to manage the almost always associated significant mood disorder. (If you hurt all the time and can’t sleep, guess what happens?) Some of the most troublesome issues, however, are not clinical. I recently wrote about the increasingly common - but problematic - use of urine drug screens (UDS). Similar issues underlie the (mis)use of ‘narcotic contracts’ as a requirement for prescribing opioids for chronic pain.
Ordering periodic urine drug screens (UDS) on patients being treated with opiates for chronic pain has become so common it is now the de facto standard of care. That doesn’t mean it benefits patients.
Every year when I brought my chain saw in to be serviced and have the blade sharpened, Reggie tried to get me to buy a set of chaps. They weren’t cheap, and, while I was not the least bit sanguine about the destructive power of the saw, I used it infrequently, only in good conditions, and with care. The chaps were a garish orange, and I always declined. Reggie always shrugged, looked disgusted, and rang up my bill.
I love taking care of patients and have enjoyed my 37 years (and counting) as a primary care physician. When I stop, it won’t be because I am rich, bored, or have lost interest. It won’t be because I am tired (though I am). It will be because of friction.
The 15 minute appointment slot is dead. To borrow from Monty Python, it is not resting, stunned or pining for the fjords, but definitely deceased, stone dead, is no more, has ceased to be, expired and gone to meet 'is maker, a stiff, bereft of life, run down the curtain and joined the bleedin' choir invisible.
As medical institutions roll out one new broken quality protocol after another, I have struggled for a way to point out the irrationality of this approach. Reading some commentary about the US attempt to achieve excellence in international soccer during the recent run-up to the World Cup gave me an idea.
When this happens, I never know whether I should be frightened or enraged.
It’s been four years since my Dad died. Sometimes I think of it as ‘only’ four years ago, and sometimes I think of it as a long four years ago. But I still think about him often and he remains a daily presence for me, through the things he stood for and the way he lived. A few examples come quickly to mind on Father’s Day.
Information is the currency of medical care. Transparency is the way it is vetted. Communication is the way it is shared. Collaboration is the way it generates patient-centered outcomes. The right information must always be available to the right people at the right time in the right format.
And, by ‘available to the right people’ I don’t just mean the PCP or the consultant.
I mean the patient.
Today on the trip from Auburn (Maine) to Montpelier (Vermont) my wife spotted the Snowy Owl she had heard was hanging out near the Elk Farm just north of Snow Falls. It was sitting on some wires over Moose Lake Brook. Check below for my photos…
When your clinician suggests a test, here are seven questions you should consider asking. (And if you are a clinician, you should be asking yourself these questions before you recommend the test.)