I was very busy yesterday. In addition to the Philly Inquirer piece, I also spoke with the lovely Taunya English at WHYY.
Yesterday I was in the paper. Today I’m on the radio.
Have a listen.
It’s kind of amazing how a big colorful picture can dominate a news story even when it has precious little to do with the subject at hand. To wit, this image:
now graces the top of page A3 in today’s Philadelphia Inquirer, illustrating an article headlined:
Paid more, doctors saw more Medicaid patients, Penn study finds
In other news: Water is wet.
Pardon my snark. I suppose demonstrating things that are intuitively obvious can be useful at times. Especially when dealing with the government, which includes large numbers of people who refuse to believe just about anything that hasn’t passed across their desk in triplicate.
So the big news for the day was that there is now actual evidence that increasing payments (not “reimbursements“!) to doctors allows us to provide care to people for whom we would not otherwise be able to do so. Able; not just willing. However, as I am quoted somewhat extensively toward the end of the piece, for many of us it wasn’t enough.
Here’s why, though (and this didn’t make it into the article): that $35 quoted as an office visit payment from Medicaid is a fiction, at least in my state. See, Pennsylvania administers Medicaid (it’s called “ACCESS”; Orwellian, isn’t it?) entirely through managed care programs. Capitated HMOs. There is no way for any doctor to get paid fee for service for Medicaid in Pennsylvania. Apparently they publish fee schedules to fulfill ACA requirements. But whenever I try to bill for my services, all I get is a rejection with the notation, “Member is eligible for a managed care program. Please contact the appropriate program.”
I joined in with the nascent HMO movement back in the early 90s, right when I was starting up my practice. At the time, they were the only shows in town. I hated them because of the way they kept trying to force me to balance my own bottom line against the welfare of my patients. I pretty much always came out on the side of the patients, but the resentment towards the insurance companies was deep and abiding. I only participate in two of them these days, and only because I am required to by an “All Products” clause in my contract. (If I don’t take the HMO, I can’t participate in the PPO.) But long ago I made the business decision not to join any more of them. Guess what: that includes all of Medicaid. Oh well.
Make no mistake. It’s a fine article and I’m very pleased to be part of it. So today my picture is in the paper. Why? Because I was able to pull a still image out of a video from 2012, crop a screen shot and get it in by 5:00 pm. Also because I’m a scintillating interviewee brimming with pithy quotes, of course. But after this news cycle ends and my 15 seconds of fame are over, I’ll still be here, longing to provide care for the less fortunate in my community but not willing to go broke doing it.
That’s my story.
I saw a patient the other day who was finally sober, again, after several relapses. She was working the program and doing very well indeed. She mentioned that she had gone to a yoga class, and then made the following comment:
It’s so much easier when I’m sober.
Which got us thinking about all kinds of other things that are easier when you’re sober:
Then again, in fairness, there are several things that are much easier to do while drinking:
I’m sure there are plenty of other things for both lists, but this seems like a good start.
Exciting recent research about the benefits of restricting eating to a certain window of time during the day: it works. On mice, at least. Granted you can’t extrapolate directly to humans, yet it supports my empiric observations that people who eat at night (technically, “when they’re supposed to be sleeping”; mice are nocturnal, so in the study, they were restricted to eating at night, corresponding to “when they’re supposed to”) find it very difficult, if not impossible, to lose weight.
Yet I find myself wondering whether it’s the restricted eating period, or the enforced fasting that’s doing the trick. When you’re talking 12 hours vs 12 hours, this wouldn’t seem to be much of a distinction. But here’s where it comes into play.
What if I try to eat only during a certain window of time during the day — say 7:00 am to 7:00 pm — and screw up? Can I get back on (biologic) track by waiting a full 12 hours since that last indiscretion? Although the research doesn’t yet exist, I’m going to bet Yes. At least, it’s a tweak to my current weight loss program (basically just writing down everything I eat, which worked before) that’s not all that hard to do.
If I know I have a late dinner planned as a special event, I wait until later in the day to begin eating. Then the next morning I just wait 12 hours after I finished the night before.
If nothing else, it’s a strategy to help get through the holidays and other times when special events collude to sabotage the best dietary intentions.
I do not have a foodie child. Not one living at home, at least. (Though I’m not sure if promising to try one new food a week but being an accomplished cookie maven qualifies as a true foodie. Sorry, DinoDaughter.) However I found myself jealous of a patient the other day on account of hers.
There’s a game in my family. We call it the “What do you want for dinner?” game. The object of the game is to be the first to ask the other, “What do you want for dinner?”, thus forcing the other person to make the decision. (This doesn’t always work. DDS’ answer is often, “I don’t know. What do you want?” In the context of the game, this is cheating.) But I have a patient who doesn’t have this problem.
Patient to son: What do you want for dinner?
Foodie son: I want that french dip roast something in the crock pot…Never mind. I’ll text you the recipe.
And he does. Here’s the link: http://m.allrecipes.com/recipe/16239/easy-slow-cooker-french-dip/
Here’s the recipe:
And he follows up through the day, texting:
Did Dad get the right rolls?
I’m leaving a little later than I thought. Save some for me.
Is it any good?
Is there any left?
(Answers: Yes, Okay, Oh yes!, and Yes.)
What a fun kid.
Not complaining. None of my kids are still at home, unlike the above-mentioned one. But it must be nice to get such a decisive answer to that age-old question.
Patient-linked article on Facebook about the tragic case of a 26-year-old woman in Wisconsin who died of sepsis from pneumonia as a complication of the flu, despite having received a flu shot. Somehow this now becomes a reason not to get flu shots. Say what?
Maybe she ate tomatoes. Did you know that everyone born before 1890 who ate tomatoes is now DEAD? Tomatoes are deadly! Don’t eat tomatoes.
Actually, the first thought that popped into my head was to wonder if she was pregnant. It’s known that pregnancy greatly increases the risk of serious complications from the flu.
The real take-home lesson from this tragedy is NOT the lethality of flu shots, but the perils of failing to promptly recognize and treat sepsis. Just because this year’s flu virus managed to outsmart the vaccine manufacturers, who had to decide nine months agoa which strains to include in this year’s shot, does not mean that flu shots are worthless. Quite the contrary.
Funny how you don’t see the thousands of reports of “perfectly healthy” people who died of the flu but didn’t get the vaccine. I guess those stories are too “dog bites man” to make the news. Doesn’t change the fact that not getting the flu shot is far more dangerous than getting it, despite the prevalence of the post hoc ergo propter hoc logical fallacy.
Here’s where I should insert all the correct information about the flu and flu shots. Fortunately, this lady has done it for me. Click through; it’s well worth it. And come get your flu shot. (I’m talking to you, FG.)
First patient this morning began with a question:
What’s this new coxie vaccine something-or-other I’ve been hearing about? Can you explain that to me?
Cox? Oh, you must mean Pneumococcus. Yes, I can explain that:
There’s a very common germ that lives on our skin and in our noses, and usually doesn’t cause us any trouble. It’s full name is streptococcus pneumoniae, but we usually call it by its nickname: Pneumococcus. It originally got the name because it’s a fairly frequent cause of pneumonia (lung infection), though it also causes other kinds of infections, like skin, bloodstream, and lining of the brain (meningitis.)
There are different strains of this germ that are exactly alike except for different antigens (proteins, sugars, or some combination of the two) on their surface. We call those “serotypes” and they’re important because it’s how our body recognizes them, and protects us from them by making antibodies; separate antibodies for each serotype.
There are several vaccines that have been approved against pneumococcus. One is called Pneumovax (which most people refer to as the “pneumonia shot”, but it’s against the germ, not the disease. You can still get pneumonia from other germs, and the shot protects against pneumococcal infections other than pneumonia), and it protects against 23 different strains. It’s currently recommended for everyone at age 65, and for some people younger than that who are at higher risk for pneumococcal infections. There’s another called Prevnar that contains 13 different antigens (12 of which are also in Pneumovax) but because it’s made a little differently (“conjugated”) it’s more effective. (It produces a stronger immune response, meaning higher antibody levels.) Prevnar was first approved for infants and young children to protect them from meningitis caused by pneumococcus, but is now also recommended for adults.
So what does that mean for Pneumovax? Are you still supposed to get it? Are you supposed to get both? When?
Here are the new recommendations?
To which my patient replied:
That makes a lot more sense.
Turns out most cancers are probably the result of random mutations. Bad luck; nothing more. Sure, things like smoking don’t help, but, if we’re being honest, isn’t it always among the first questions we ask when we hear someone has cancer? Talk about adding insult to injury to blame the victims of plain dumb luck.
When you stop to think about it, just about everything of any importance in life comes down to luck. Born American; born white; born affluent. #WhitePrivilege is real. The lasting advantages in life from a first-rate education, paid in full? Largely luck. How much credit to take? Intelligence enough to make the most of all the opportunities; hopefully with humility enough to recognize the relative role of luck over any intrinsic merit. Think about it: if medical schools only take 10% of qualified applicants, then for every MD graduated there are nine other folks out there who could have done it too; maybe better than those who did. Why me? Why not them?
Sheer dumb, blind luck; nothing more.
They weren’t brown enough, or thin enough, or crisp enough. But the anise oil (not extract) gave them a flavor that was magnificent, and aside from the color, they were pretty enough. But they weren’t all consumed at the party last night, so what was I to do with 16 leftover too-light, too-thick, too-soft pizzelles?
Pair them up, slather on a thick layer of Nutella™, refrigerate for a while, then cut into quarters.
Doc, can you write me a note?
All depends; what for?
1. I forgot to get a note for work (or school) when I was in to see you yesterday.
2. I’ve been out sick for three days. Just a cold, nothing you can really help me with, but my work (school) insists on a doctor’s note.
Sure, I can do that. Some employers can be really anal about doctors’ notes.
3. Can you write me a note to go back to work after an injury that was treated by another doctor?
No, sorry. You have to go back to the other physician (ortho, workman’s comp doc) for that.
4. I’m looking for another job and I have an interview tomorrow. Can you write me a doctor’s note for my boss so they don’t find out?
Um, no. That’s called lying. Figure out something else (that doesn’t involve me.)
5. I’m in nursing school and I don’t want them practicing blood draws on my right arm. Can you write me a note?
You don’t need a note; you need a backbone transplant. Just say no.
6. [Woman diagnosed with flu] Can you write a note telling my husband I need to rest?
Absolutely. No cooking, cleaning, or housework for six weeks. Here you go!
*With apologies to Amadeus.
It’s really quite easy to kill a doctor. Here’s a step-by-step process guaranteed to succeed at least 400 times a year:
Be sure to denigrate medical students whenever possible. Even if they’ve come to the profession later in life and have accomplished all kinds of amazing things personally and professionally (which don’t count, of course, since those are other professions) they don’t know squat about medicine and you do. Make sure to emphasize their ignorance and inexperience at every turn, because it’s the only way to prove that you know more than they do, which of course means that you’re a better person than they are. The fact that as a group they’re all at the very top of their peer group in motivation and intelligence is irrelevant.
Tell them they’re lazy when they say they’re tired after being up for 36 hours (since they’re not residents, they don’t have work hour restrictions). Tell them they smell of formaldehyde from the anatomy lab and make amusing gagging noises whenever you see them. If all else fails and they are actually able to competently work up a patient, plus answer the most esoteric questions you can think of, impugn their sexuality or tell them they dress weird. Don’t worry about being judgmental; patients are the only ones deserving of your respect. And other doctors, of course; well, the ones ahead of you in training at any rate. But only in your own specialty.
Don’t let up once they graduate from medical school.
The first year of residency training is a great time to kill doctors. They’re foundering around desperately trying to figure out how to function in their new roles. Most of them are also drowning in debt and watching as their non-medical friends (if they still have any) get married, buy houses, and have kids; you know, have lives. Yell at them for everything that goes wrong with their patients, whether it was their fault or not. Tell them it builds character.
Hospital administrators have an important role.
Make sure the physicians you hire understand how important it is that they show up for their shifts, but don’t give them any input into the schedule. Ignore their scheduling requests, but tell them they were lost; better yet, imply that they were never sent. Same with messages, committee meetings, and other administrative responsibilities. Make sure there are enough of these to make it impossible for doctors to take care of the patients. Otherwise the patients may actually think it was the doctors, and not your wonderful hospital (or hospital system) responsible for their recoveries.
If you’re not a particularly affluent institution, make sure that the food, decor, and customer service at your institution is as bare-bones as you can, but lump everything under “Medical care” in your patient satisfaction questionnaires so the doctors get blamed. Then tie their payments to those satisfaction scores. Win-win, for you.
Be sure to switch up your EMR annually at least, but call it “Upgrading” and label any doctors who complain as “disruptive.” It helps if the main hospital, Emergency department, and Radiology departments all run separate systems that don’t interact. Make sure each system requires different passwords, and require that they be changed at different intervals. Forbid physicians to write them down. Security, you know.
Don’t stop once you’re in practice.
Pick on your younger colleagues for their inexperience. Whatever you do, never tell them they’re doing a good job. Stick them with as much holiday and weekend call as you can. After all, you’ve paid your dues; now it’s their turn. (Tell them that.) Don’t listen to your older colleagues either. They’re just old farts whose knowledge is waning. Who cares about their decades of experience? Just tune them out when they start talking to you, then nod condescendingly and walk away.
Practice that condescending look and use it at hospital staff events. Make it a point to ignore newcomers. Concentrate on talking just with your friends and laughing at inside jokes, especially when others are around. Don’t return their calls, and don’t take their calls if you can possibly help it. If you accidentally wind up on the phone with the patient’s primary physician, just tell them you’ve got it all under control, and that he (and the patient) are so lucky you got involved when you did.
Target your efforts.
None of the above actions in and of themselves is likely to drive a doctor to suicide. However if you manage to select individuals with a personal or family history of depression, those with poor social supports or self esteem issues, you can greatly increase your chances of killing a doctor. Concentrating on certain specialties where there may be easier access to more lethal means, like anesthesiology and surgery, may also raise your yield. Don’t despair, though. Intensively applying all the strategies above and more (you know what to do; much of it has been done to you over the years, and may still be occurring as we speak) to doctors in any specialty represent proven ways to kill them.
Now you know how to kill a doctor.
It’s really not that hard. The question is: Why would you want to?
Everyone knows doctors are only in it for the money. Not.
The most rewarding thing about the practice of medicine is making a difference in the lives of our patients. Whether it’s saving a life with surgery in the middle of the night, handing over a newly-delivered baby, or just reassurance that it’s only a cold and not bronchitis and everything will be all right; those are the moments we all treasure.
Patients have many ways of showing their gratitude, almost all of which are warmly appreciated. From flowers in the dead of winter:
to homemade holiday cookies (even store-bought), or just the sincere “Thank you” at the end of the visit, patients’ expressions of appreciation always make our day.
But yesterday, a family went above and beyond.
There was only about two inches of it, light and fluffy. No big deal. But after leaving my office reassured that her toe wasn’t going to fall off, this teen and her mom cleaned the snow off my car.
How much would you pay a valet to park your car?
Certainly a job consisting of getting into a car not your own, safely navigating it from point A and parking it at point B, then reversing the procedure at your request is a service that deserves compensation. The question is how much?
Does it depend on the car? Or the skill of valet?
I would say, talking to various people, that the appropriate amount lies somewhere between five and twenty dollars, depending on the specific locale.
Now consider how much you would pay someone to draw your blood, a job that consists of the following steps:
Here’s a question: who deserves to be paid more? Or in other words, what is the relative value of each task?
Medicare pays $3.00 (less 1% for the sequestration) for the procedure, coded 36415. Other insurers pay from $2.25 to $5.75, if they pay at all.
Because I draw blood in my office, I can legitimately add to the list above:
By adding (“bundling”) the things on the second list, I legitimately bill these encounters as Level 1 office visits. Still makes you wonder about the pricing: I guess people care more about their cars than about their arms.
My New Years *Resolutions* are going well…five days in. The cat box is immaculate, I’m more than halfway through The Lost Gate, I’m on track to post here every single day for at least a week, and I just finished the paper today.
Speaking of today’s paper: What should I espy in the Health section of my Philadelphia Inquirer but a familiar name! My good friend Margaret Polaneczky (I get to call her Peggy), my old blog-buddy from those heady early days of medblogging quoted in an article about helping women in their 40s make informed decisions about mammograms. And here it is: Breast Screening Decisions, Peggy’s interactive online tool that *rocks*. Check it out.
For the record (and just to prove I knew her when), here’s my reaction to the brouhaha instigated by the original USPTF mammogram recommendations: Mammograms for the Masses…complete with a comment from Peggy herself. Even then she was working on the recently launched tool.
Well done, Peggy, and thank you. My 40-something ladies will love it.
First world problems: Problems complained of by those living in a wealthy, industrialized nation that third worlders would probably roll their eyes at. Things like which car to take when going out to dinner, or where to go out to dinner, or what to order when going out to dinner.
The other day I was chatting with a gent who was fretting about getting his tax information together for his accountant. He was
bragging complaining that a stock with a large capital gain was forcing him to forage around for capital losses to offset it.
That’s not just a First World Problem; that’s a “1% problem.”
I’ve been enjoying Twitter for a while now (@DinoDocLucy for any wannabe followers). It’s providing me with links to all kinds of fascinating things I never would have found otherwise. It’s also really cool how often I come across things that have nothing to do with medicine but everything to do with my practice.
I thought the title looked interesting, so I clicked through. It turned out that the reps in question were calling on libraries, as the post was on a blog about scholarly publishing. Still, several points (sort of) applied to pharma and other reps who come a-calling on me.
Then came point #5: Responding to Affordability Statements with Value Arguments
…For the last several years I have been fielding pitches from a particuarly aggressive sales rep who very much wants to sell my library a backfile database at a price of roughly $150,000. When we tell him that we don’t have $150,000 available for such a purchase, the response is always a long explanation of how important and valuable the database is. We couldn’t agree more. But the value proposition doesn’t make $150,000 magically appear in our budget. …Takeaway point: Value and affordability have nothing to do with each other, and price trumps value every time.
Hello! That’s what I’ve been saying about electronic medical records all along. All the “value” they add is completely irrelevant when I can’t afford them in the first place.
That’s the biggest reason I finally adopted a free EMR. When you start by maximizing Affordability (with a price tag of zero), Value approaches infinity.
News non-flash: comparison of various diets (low carb/Atkins, low carb + low fat/South Beach, low calorie/Weight Watchers, and whatever-the-hell-the-Zone-diet is/protein-carb ratio) shows no difference in long term outcomes, defined as sustained weight loss, with the attendant presumed decrease in cardiovascular risk factors and events.
Sorry; no great surprise here. But I think it’s because nutrition research has a huge blind spot: not adequately controlling for type 2 diabetes/metabolic syndrome.
Let me explain.
I have a hypothesis that people with the inborn error of metabolism (insulin resistance) that in the setting of dietary carb overload and low levels of physical activity result in overt glucose intolerance and, eventually, diabetes, respond better to low-carb diets than people born with normal carbohydrate metabolism. By not carefully screening them out in the research, negative results are meaningless.
Current definitions of diabetes, “pre-diabetes”, metabolic syndrome, and so on center on blood sugar levels in both the short term (fingerstick glucose measurements) and long term (the 3-month horizon afforded by the hemoglobin A1c). The problem with this is that the increased cardiovascular risks from these conditions appear to manifest independently of actual blood sugar levels. Witness the disappointing results of studies of so-called “tight control”: modest reduction in microvascular disease (kidney failure and retinopathy) but no significant effect on macrovascular disease (heart attacks and strokes.) This says to me that there’s something more than just hyperglycemia going on in these patients.
We also know that lifestyle issues (read: exercise), not smoking, and treatment with lipid-lowering statin medications DO decrease these risks in these patients. But who are they?
Diabetics, of course. Pre-diabetics too, plus anyone with metabolic syndrome (high triglycerides/low HDL/abdominal or “apple” shaped fat). Women with PCOS and/or a history of gestational diabetes. These folks are relatively easy to identify, whether or not they’re excluded (or at least controlled for) in nutritional research. But I think there’s another group of folks who have this inborn metabolic error but who, because they’re already “living right” (exercising, maintaining ideal body weight, not overdoing dietary carbs) have perfectly normal blood sugar levels, and therefore completely normal A1c levels.
How to identify them? A few thoughts: family history. Anyone with any first degree relative with either diabetes or any of the above equivalents (PCOS, gestational diabetes). Or we can check insulin levels. Because the inborn metabolic error is that of resistance to insulin, these folks walk around with higher insulin levels in order to maintain normal blood sugar levels.
Control future dietary studies for diabetes — REALLY control for it — and see what turns up. Better still, select out people who don’t have it. I bet you’ll see better, more robust responses to any version of carb restriction. But until inborn errors of carbohydrate metabolism are adequately controlled for in dietary research, I don’t think there are any valid conclusions to be drawn.
Happy New Year to all. New month; new year; new calendar. Everything begging to be new and fresh, even while the days are still too short and the air too cold, with the worst of the winter yet to come. What cheer!
Lots of people talk about why New Years resolutions don’t work and they’re right. Hence the quotation marks.
Technically what follows aren’t Resolutions. They’re not goals, or vague aspirations like “get in shape”, “lose weight”, or “Be nicer to your sister.” (Hi, Dr. Kensingon!) They’re more like items I want to add to my daily to-to list. Things you don’t even bother to make a to-do list for because you just do them every day, like taking your pills, brushing your teeth or making your bed (all of which I do.) They’re things I really want to do each day — and often do; just not always.
In order to help myself commit, I figure I should write them down. Even better, write them down publicly. So here goes:
1. Write every day; even just a little.
It doesn’t have to be just a little, and I’m sure once I get started, I’ll often do more. I just have to sit my tush down in front of the damn screen and do it (Nike style.) I’ve reclaimed my writing desk from DDS, and even though it’s in the bedroom instead of my writing room, it turns out to be better than the kitchen table. So no more excuses. At least once a day, sit down and write. It may be a brief blog post (or a longer one), or the next installment in Dr. Lucy’s Ridiculously Simple Guide to Health and Wellness, or who knows what else. But I really would like to get back to writing every day.
2. Read every day, even just one chapter.
Maybe this is the source of a lot of my malaise of the last year, but I somehow got away from regular reading. I had a whole stack of books, but I started having trouble getting into things. Now thanks to the Jock, who gave me two new Orson Scott Card books for Hanukah (the Mither Mages series), I’ve begun reading one chapter before bed. Rather like nibbling at a box of chocolates one at a time instead of pigging out on the whole thing, I’ve decided to savor these slowly instead of “waiting until I have time to read as much as I want” (which only happens on planes anyway). An added advantage is that it keeps me away from backlit screens (cough*Candy Crush*cough) right before bed, which seems to be improving my sleep.
3. Play the piano every day, even just a little while.
A far cry from the distant childhood refrain, “Did you practice yet?” Now that my piano is right out in the open (and tuned! Thanks DDS), my Handel album sitting open and ready, I’m getting great pleasure sitting down and re-establishing that old muscle memory. There has been talk of lessons, but like those who insist on cleaning up for the cleaning lady, I want to get better first. I know how the music is supposed to sound (because I used to make it sound like that) and all it’s going to take is time.
4. Clean the cat boxes every day.
Okay, this one is right up there with pill-taking and teeth-brushing. At the moment, I confess it’s not. But it should be. Which is why I’m including it here.
5. Read the newspaper every day.
I’ve gotten a little lazy on this one. I do eventually read it, often 2-3 days (or more) at one sitting. But if I do it every day, it’s much more efficient.
6. Eat only during an eight hour window every day.
This one’s new-ish. I’ve had good experiences with modified fasting, and bad experiences with eating at night. Following this guideline should be helpful. Whatever time I first eat something in the morning, eight hours later I’ll stop. I’m definitely going to continue writing down everything I eat, which I have done every single day for over five years now. No reason to stop. And I really do have to lose the weight I’ve partially re-gained over the last four years.
7. Walk every day, at least 30 minutes.
Who am I kidding? This one’s not going to happen at least until the weather gets nicer. I’ll give it a shot, but I’m not going to beat myself up if it doesn’t happen.
Ever wonder what your doctor is thinking while taking your history? If we’re doing it right, we’re looking at you instead of a computer. We’re making appropriate eye contact while displaying welcoming body language. And we’re letting you tell your story with as few interruptions as possible. Clearly we are listening intently, but did you ever wonder what’s going through our minds while you’re speaking?
I’ve been thinking about this lately in the context of teaching medical students about history-taking. They’re being taught all the right questions to ask and how to ask them (body language, open-ended, etc) but it often seems like they don’t know what they’re supposed to be listening for, or how to elicit the kind of information that will let them make a diagnosis (which is, of course, the necessary prerequisite for appropriate treatment.)
So here’s an analogy to try and help both patients and learners better understand what’s going on inside the doctor’s head:
Imagine that someone is telling you a story. There are lots of different stories it could be, but the person has no idea which one it is. In fact, as far as he’s concerned, no one has ever heard the story before, because it’s the first time he’s telling it. But he’s telling it to you because he’s hoping you’ll recognize the story, and tell him how it’s going to end — or, more importantly, intervene to change the ending, if it happens to be a story that ends badly.
What are your prerequisites? First, you need to know a lot of stories. Because you can’t help the storyteller if you’ve never heard of his story. (Even if you’ve never actually heard it, you need to have heard OF it.) Next, you need to know what elements are intrinsic parts of the story, and which ones are minor details that can vary from one telling to another without materially affecting the essence of the story. There are also significant clues you can take from who’s telling you the story. Younger women, older men, little kids each seem to tell their own specific stories. Timing also matters. Some stories are told more often within several months of giving birth, or within a week of major surgery for example.
Say the storyteller begins, “Once upon a time…”
You wouldn’t immediately jump in and start asking a whole bunch of specific questions like:
No, you’d let the storyteller go on as long as possible on his own.
“Once upon a time, there was a little girl in a blue riding hood, whose mother sent her off to her grandmother’s house with a basket of goodies.”
If you’re sufficiently familiar with enough stories, you should immediately recognize that the color of the girl’s clothing may not be as important as getting her to turn around and NOT get any deeper into that forest until you’ve had a chance to do a scan and a Wolf-ectomy. Or at least make sure she’s got a hunter escort.
Even though the stories are basically the same, each person tells them differently. Think about how many different ways you’ve heard stories that are basically Romeo and Juliet.
As the storyteller is relating his tale, you start thinking about the various possible stories he could be telling. Once you start to recognize the story (or even what kind of story: is this a short one where nothing much happens of consequence, or one where things don’t end well for the protagonist?) you begin to listen for specific details from one story or another. As you hear them, they lead you down the path towards figuring out the correct story. If they’re not forthcoming, you try and ask open-ended type questions to elicit them. Things like “What kind of place was the princess living in?” as opposed to, “Was she in a forest? Was she in a town? Was there a castle?” (analogous to asking, “What does eating do to the pain?” instead of, “Is the pain relieved by eating or does eating make it worse?” Open-ended instead of yes-no.)
Once you’ve heard a hundred people tell you the story of their gallbladder (“I’ve been getting this pain in my stomach, up high on the right, for a while now, but it’s getting worse after I eat, especially fatty foods. It nauseates me and sometimes I throw up,”) or the story of their appendix, or the story of their hemorrhoids, or the story of the flu, or the story of their ulcer or their pneumonia or their MS or their UTI…you get the idea — you start to recognize it within a few sentences. You want to keep listening, though, because this just might be the person telling you the story of their brain tumor instead of the story of their migraine headaches. The best way to figure it out for sure is to keep listening, which means keep the storyteller talking.
There’s lots of overlap between stories. There are many conditions, like upper and lower respiratory infections, viral syndromes, gastroenteritis, pinkeye, and many other conditions which will all get better with time. Assuming you’re very confident that the story is one of the many short simple ones with lots of overlapping features where nothing really bad happens, recommending things like rest and plenty of fluids will often result in the storyteller living happily ever after. But your patient is counting on you to correctly recognize which story they’re telling, to know how it progresses — including how it ends — and how to intervene to change a bad ending to a better one.
If you decide too soon that you know what story it is, you may stop listening for clues to other stories and miss them altogether. Then, as the story progresses (or as the disease progresses along its natural history) you may be making things worse instead of better, because you’re not getting the right story. Many times, the most important clue is recognizing that there’s a significant detail that just doesn’t fit. The girl in the blue riding hood is being imprisoned in a tower with no doors, and happens to have really long hair. An adult with a sore throat that began with a runny nose two weeks ago is now getting much worse; Rapunzel does not have strep.
There are two basic cognitive strategies to figuring out the story. At first, when you don’t know many stories or what you can do to modify the scary ones, you do something called “hypothesis testing.” You take the first story that pops into your head and start asking all kinds of questions specifically about that story. Once you decide that’s not it, you take the next most likely one and start specifically seeking information to confirm or deny it. And so on. Thinking about it in terms of trying to figure out which fairy tale someone is telling you helps you appreciate the inefficiency of this approach.
The strategy used by experienced clinicians is called “pattern recognition.” That’s what we mean when we tell learners to “listen to the patient,” and “the patient will tell you what’s wrong.” As we listen, we hear familiar riffs: chest pain that worsens with exertion steers us toward the heart; pain with nausea after eating pushes us towards the gall bladder. We have to keep the patient talking, but we have to know how to ferret out key details that will guide our questions when we finally get around to asking them. You just need the confidence that you will recognize the story the patient is telling you.
How do you learn these stories? Aside from hearing them from lots of different patients, of course, you can read them in medical textbooks, where they are called things like “Presentation” and “Natural History”. Except in this case, you know what the story is (because the title is on top of the page), as opposed to learning how to figure out which one the patient’s telling you.
These stories have also been called Illness Scripts. Most of the academic work on them has been done with groups of medical students in small group settings. But I believe there would be value in writing them down in transcript form, just as a hypothetical patient might relay the story, with a sidebar containing the contemporaneous text of what’s going through my head as I listen to the patient. Symptom-based as opposed to diagnosis-based, I think it would be useful to entry-level medical, nursing, and allied health care students to help make the jump to pattern recognition from hypothesis testing.
Any takers for a collaboration?
It’s been a fascinating week or so listening to everyone weigh in on which response they thought I sent to my patient (also here.) The general consensus, unsurprisingly, was that the first was far too cheeky — not to mention insulting — to effectively convey the necessary information. The second, of course, was the one I send every day, day in and day out. Just this once, circumstances conspired to allow me to send the first.
Let me explain.
I’d like to begin by quoting myself:
I find it amusing to intentionally adopt a far more curmudgeonly attitude here than I would ever dream of displaying in meatspace. It’s part of the fun of blogging, which is why I’ve been doing it now for almost eight years.
All I ask is recognition that my public blog persona is different from my personal, real self.
The first message was perceived as an expression of my frustration with a patient who wouldn’t comply with recommended treatment while complaining about one of the manifestations of her condition. (There were also some interesting digressions about hypothyroidism and weight loss, none of which actually apply. Remember the first rule of blogging: anonymize! Suffice it to say that her TSH wasn’t 7; it may not have been a woman; the issue may not have been weight loss; etc.)
Here’s the thing, though: in real life, I don’t actually get frustrated with my patients. Really. I’ll admit this wasn’t always the case, however the older I get, the less I care. Not that I don’t care about my patients, but it’s become much easier to actually live the truism embodied by the old Polish proverb, “Not my circus, not my monkeys.” ie, My patients problems are not mine. If patients don’t take their medicine, they’re the ones who live with the consequences. (I take my Synthroid.)
This particular patient was also a health care professional herself. In fact, when I read my first email aloud, my work-spouse said, “That sounds exactly like how she talks to her patients.” Because it was. She’s a cheerful, vivacious, funny, sarcastic person who doesn’t pull punches with her patients, her family, or me. When she said, “Nah, I stopped taking [the synthroid],” it was with a sardonic smile that conveyed recognition of the fact that she was being irrational. Cost wasn’t an issue. Understanding its purpose wasn’t an issue. I don’t think she could articulate precisely why she stopped it. But she had, and here she was, back again, bitching yet again (albeit good-naturedly) about her weight.
So when the repeat blood work confirmed the condition (or at least the distinct possibility that taking the med would help) the first response kind of wrote itself. In a way, I may have been channeling her voice talking to herself. One thing I’ve learned in my own weight loss journey is that no one can be harder on me than I am on myself.
Couple of other things edited out for the sake of the blog:
After the CAPS, I added “(Sorry for shouting)”, and after “Dig?” at the end, I added (“Love you.”) Finally, before hitting the SEND button, I picked up the phone. I didn’t reach her but I left a message, “Just to let you know there’s an email coming, meant to be funny, hope you don’t take offense.” The rest of it, BTW (except for the clinical specifics) was verbatim. ie, “Big girl panties” and all.
Bottom line: She loved it. Message received loud and clear, along with a good laugh. Customized communication at its finest.
Would I ever write such a message again? Perhaps. But only if I were absolutely certain it would be received as intended, as it was this time.
Thanks again to all who responded.
Middle-aged lady, twenty pounds overweight.
Doing everything I can, doctor. Everything imaginable. Diet: I eat practically nothing. Exercise: all the time! Weight Watchers doesn’t work. Jenny Craig, South Beach, the Zone; I’ve tried it all. Nothing works. Have to lose weight. Have to lose weight.
Yadda yadda yadda.
Oh look: a few years back I diagnosed you as hypothyroid and gave you some Synthroid. Are you taking it?
Nah; I stopped that. I just didn’t want to take it.
Hm. Send some blood work. Low and behold: TSH is 7. That’s high, and it means her thyroid is underactive, which is probably a big part of why she’s having so much trouble with her weight.
She’s asked to be notified by email, so I sit myself down at my little keyboard and compose:
Labs are back; report attached. Cholesterol, sugar, blood count all fine. BUT: I don’t want to hear one more word from you complaining about not being able to lose weight IF YOU DON’T TAKE THE DAMN SYNTHROID. Your TSH is 7. That’s hypothyroidism. Until we get you titrated to a dose that gets your TSH below 2, nothing is going to change, including difficulty losing weight. So put your big-girl panties on and let me know where you want me to send a new prescription for synthroid. Then get back here in 6-8 weeks for another TSH. Dig?
But my finger hesitated over the SEND button. Could I really send that?
I hit SAVE DRAFT and started over:
Labs are back; report attached. Cholesterol, sugar, blood count all fine, but the TSH is still a little high. I really think you should try the synthroid again. It’s almost certainly the reason you’re having so much trouble with your weight. Why don’t you let me know what drugstore you use so I can send a new synthroid prescription. Then we can check another TSH in about 6-8 weeks. Okay?
I read both versions over again. Back and forth. Over and over.
Then I hit SEND.
Guess which one?
Chief complaint: “I’m concerned about my balance.”
Further questioning reveals a subjective complaint of “wobbliness.” Has never fallen. No vertigo. Romberg testing is negative (standing with feet together and eyes closed sways only a little). Neurologic exam is normal.
I gently suggest that he try using a cane, mainly for reassurance while walking.
“Oh, Doctor. I don’t want to do that.”
“It’ll make me look like an old man.”
Uh, sir: you’re 88. I think that ship has sailed.
Patient with multiple medical problems (diabetes, COPD, hypertension, hyperlipidemia, headaches, arthritis; you know, your basic Baby Boomer) comes in with a new symptom: food gets stuck going down. It’s been going on for a while now and getting worse. Liquids are becoming problematic as well.
I’m worried. Esophageal cancer is the main concern here, so off he goes to endoscopy.
Good news is that there’s no cancer. Bad news is that brushings show infection with candida. It’s a yeast infection of the esophagus. Treatment begins, but now we have another problem: Why did this happen? Esophageal candidiasis isn’t something that happens to people with normal immune systems. Sure, the diabetes leaves him a little immunocompromised, but not enough for this.
Yes, he’s on an inhaled steroid for his COPD, but he specifically tells me that he’s very careful to rinse out his mouth every single time he uses it. Every single time. Very carefully.
Let’s see; what else? HIV? Nope (I tested.)
I’m puzzled. I run through the possibilities again. Is he sure he rinses out his mouth after using his inhaled steroid?
And then what?
He swallows it.
The whole point of rinsing after using inhaled steroids is to get rid of whatever medication may still be in your mouth. By swallowing it, it’s going straight down his esophagus instead of down the drain. Instead of being safely flushed away (and contaminating the sewage system, but that’s another issue) those steroid remnants are priming his esophagus for little yeastie-beasties to take hold.
“Should I not be doing that?” he asks.
Um, no. You shouldn’t be doing that.
More followup on my post about intentionally not calling a patient with bad news on a Friday afternoon (and my karmic suffering at not receiving timely feedback after the disclosure the following Monday).
It was a 15 cm* primary malignant tumor…that turned out to be completely encapsulated! No evidence of malignancy anywhere else (and there were ten pathological specimens sent, as is customary in cancer surgery)! Stage 1! A little chemo to mop up some leaking fluid (that was still pathologically negative) and the patient will be fine.
Rarely have I experience such elation reading a path report.
The patient stopped by as well. Turns out the spouse’s work requires annual wellness checks (which we’d already done) including cholesterol levels, which I had not done when I sent tumor markers. If the pathology had been anything else (ie if it had been more in line with the radiologist’s opinion), we would have told the employer to shove it. But now that a reasonable life expectancy had been restored, I sent the test. We shared a chuckle over it.
* For any non-medical folks, yeah, that’s f-ing big.
The urologists have done it again:
Patient’s [non-prostate-related urological issue] is resolved. Annual prostate cancer screening with PSA and DRE emphasized. [sic] Re-check in one year.
Prostate cancer screening guidelines; FOUR of them: from the American Cancer Society, the American Urological Association, the American College of Physicians, and the United States Preventive Services Task Force. Go ahead; click through; read them.
Central to EACH AND EVERY ONE is the concept of “shared decision making,” recognizing that “[t]he benefits of screening with the prostate-specific antigen (PSA) test are outweighed by the harms for most men.” (American College of Physicians)
Here it is again:
The American Cancer Society (ACS) recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information. [emphasis mine]
Oh, but that’s just from a bunch of people who don’t actually take care of patients with prostate cancer.
Okay. Here you go. Guideline statements from the American Urological Association (that would be the folks who do actually take care of patients with prostate cancer):
Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years.
Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk.
Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences.
Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives.
Guideline Statement 5: The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy.
[all emphasis mine]
Nowhere in 2014 does anyone responsibly “emphasize” annual prostate cancer screening with PSA and DRE. Nowhere. Nowhere, apparently, except in the offices of stubborn specialists refusing to relinquish their old ways. They literally have their patients by the balls (well, close enough.)
I’ve addressed this before. Twice, in fact. To say I was dismayed to receive the letter above is like saying T Rex can be a bit excitable when he smells food. To keep to the subject at hand, let’s just say I’m really really pissed.
When I started practicing, it was standard procedure to treat upper respiratory infections with antibiotics. Knowledge grew. Recommendations changed, and I stopped; even when patients didn’t understand and I had to take time and make the effort to explain it to them.
What good is it to do research and make new discoveries when no one pays any attention to the findings?
Twenty-five years ago today, I hung out my shingle.
That’s a long time. Not quite half my life ago, but getting closer to that benchmark every day.
Twenty-five years. Wow. Every time I think about it, that’s all I can say.
In many ways, my practice today is more like it was in the beginning than ever before. I’m back down to just one staffer, two exam rooms, same number of phone lines, even some of the same patients.
In many other ways, my life has morphed into one that, twenty-five years ago, I could barely have fathomed in my wildest of dreams. My kids are all grown, all employed, all homeowners…and all pet owners; but all still healthy, happy, beautiful, competent, and utterly wonderful. I’m still married, albeit to a very different spouse. I’m thirty pounds thinner (yeah, I lost fifty, but twenty have found their way back), I’m growing my hair out, and I have over a dozen pairs of glasses to switch up my look every day. The most stunning change (for me) has been the new house.
Yet through all the personal changes, metamorphoses, and evolutions there has always been the practice. Office hours have shifted over the years to accommodate school schedules, but now that the kids are gone, the office schedule has settled in some. Yet the practice remains my joy, my job; my life’s work. Ongoing and ever changing, yet steady as the tides. August is busy with physicals; October we’re crushed with flu shots; flu season usually peaks around February; allergies blossom in the spring with the flowers. The cycle goes on.
There are changes there too, of course. Two moves and two remodelings; the shift to electronics and away from paper. Still, the things that remain continue to outweigh the changes.
The blog is still here as well Not nearly as active as in the past, but what is? Looking back, there’s lots of good stuff there. Not the least of which is this, written five years ago on the occasion of my practice’s twentieth anniversary:
But now as then, what I look forward to most is the people. They’re usually called patients, but what they really are is people who have done me the tremendous honor of allowing me into their lives at their most vulnerable; the best and worst moments of their lives; the beginnings, the endings, and everything in between. When I think of twenty years in practice, I don’t think about the three locations, the comings and goings of assorted staffers, or even the hospital staff and committee meetings. I remember the patients; my patients; my friends. Now as then, they are the reason I do what I do, and why I love what I do. Now as then, I thank you all.
Twenty-five more? Who knows?
I’d sure like to try.
Many thanks to all who responded to my conundrum about conveying bad news on a Friday. Lots of different answers confirmed my initial impression: there really wasn’t any “right” answer. I just did my best based on what I know about my patients. Just thought I’d let y’all know how it played out.
I picked up the phone the moment I got into the office (pretty FSM-damned early) and caught the patient before leaving for work. Conveyed the fact that I had news and that it wasn’t good. Arranged for patient (and spouse) to come for an appointment within the hour.
They reacted about as expected. It actually hit the spouse significantly harder than the patient. Tissues were proffered and accepted. They had spent the weekend reading up on some of the various diagnoses we’d discussed earlier, though not the one that it turned out to be.
But it was a good weekend for them. Mission accomplished.
Phone numbers were provided to the required specialists. More hugs offered and again accepted. After they left, I picked up the phone again and spoke with the surgeon myself, giving him the specifics and to expect the call. He reassured me that the patient would be taken care of promptly. In my experience with this practice, it usually means surgery will ensue within the week.
It’s now more than a week later, and I haven’t heard anything from either patient or specialist. Chances are that surgery has already occurred, a definitive diagnosis has been obtained, and further treatment is being planned.
But I know nothing. Out of the loop. Radio silence.
I’m confident that my patient is being well cared-for. But what about me? I’m still worried.
I know how whiny that sounds. I know I’m not the one facing major surgery and potential further treatment for a life-threatening illness. But still; I care. I don’t want to bother the busy surgeon by calling and bugging him. I’ll probably get a letter from him eventually. And I certainly don’t want to bother my patient or the spouse. It’s not their responsibility to keep me informed.
But still; not knowing is difficult. Karma for having waited until Monday? Perhaps.
The history was concerning. The exam was alarming. Labs were sent; imaging ordered; possible diagnoses, including dire ones, were discussed at length. A hug was offered and accepted, and the patient left with assurances that I would call just as soon as I knew anything.
The next day the radiologist called, which is never good. It wasn’t. Then the labs popped into my inbox. All the information was back. It was time to call the patient.
But I didn’t.
It was late Friday afternoon, and I made the conscious decision to not make the call right then.
Here’s how I looked at it: either the patient got to spend the weekend not knowing, or knowing the worst but not being able to do anything about it for three long days. I elected not to ruin the weekend.
Was I right? Was I wrong? I don’t know. I asked myself how I would feel getting that kind of call late on a Friday, and that’s how I decided. It was my call, for better or worse.
First thing Monday morning I’ll pick up the phone and make the calls to the patient, the surgical oncologist, and do whatever else it’ll take to get the ball rolling. Surgery will likely ensue within days; the surgical oncology group is really good about not making people wait.
But for the moment, I’ll carry the burden of knowledge alone, letting my patient enjoy a beautiful weekend. Well, as much as possible waiting for this kind of news.
What would you have done?
Even paranoids have enemies * and even hypochondriacs get sick.
I have a patient who is a full blown
hypochondriac sufferer of health anxiety. He firmly believes he has full-blown AIDS after a single extramarital sexual contact (non-genital) one month prior with a woman not known to have HIV. (Reality check: the other person didn’t have HIV, the specific contact as described was ridiculously unlikely to have transmitted the virus had it been present, and AIDS takes months to years to develop after actual HIV infection.) He once believed his kitchen counters were radioactive because of a news reports of toxic spillage into a creek next to his housing development. He was also concerned about having inhaled particles of styrofoam doing a project with his kid, which then made their way through through his body and were coming out in his saliva. In short, he has it bad.
But he called a few weeks ago with a new concern: his blood pressure was high at another doctor’s.
So I brought him into the office and checked his blood pressure. Sure enough, it was 160/110. Last year at his physical it had been 120/80.
He wasn’t having any symptoms (surprisingly); no headaches, no chest pain, no visual disturbances. He was just very worried about his blood pressure, which wasn’t even inappropriate.
Of course, we don’t make a diagnosis of Hypertension on a single reading. By definition, the blood pressure has to be elevated on three separate occasions before the diagnosis can be appropriately made (in the absence of symptoms and/or evidence of end organ damage). Could have been too much coffee, not enough sleep the night before, energy drinks. Any number of things can cause transient blood pressure elevations.
I sat him down and explained all this. Somewhat to my surprise, he took it fairly well. I suggested that he begin a program of regular exercise (walking 30 minutes a day, every day) and limit sodium in his diet, then come back in a few weeks and we’ll check it again.
Chances are that he does indeed have essential hypertension (he has a positive family history, as do a great many people; it’s a very common condition) and that he’ll wind up on medication for it. But I was impressed that he finally came in worried about something worth worrying about.
So how do you know when that hypochondriac is really sick?
Generally because they present with something completely different, or with objective findings (like abnormal vital signs) instead of merely subjective complaints. But the only way you’re going to know that is to keep open the lines of communication with them, even as frustrating and time-consuming as it can be.
Even though I know this guy generally isn’t going to have something serious, whenever he calls I go ahead and see him, listen to his concerns, perform an appropriate examination and testing when necessary, before blithely reassuring him nothing is wrong. There usually isn’t. Except when there is.
*Mixed attributions, to both Henry Kissinger and Golda Meir.