Focus on the Mission, Not the Score: Healing the Doctor-Patient Relationship

I recently read a post entitled “Patient Satisfaction and Doctor Requests – What’s the Score?” The post addressed the patient perception that doctors are not empathic and the physician perception that patients want to get what they want in order to be happy with their care. The content of the blog post notwithstanding, the phrase “What’s the Score?” is really what stuck with me.

What is the score?

0-0

If this is a fight, it is an unfair one with unfair rules. The doctor-patient relationship in its current state is like a marriage fraught with miscommunication, assumptions, and unspoken expectations. And let us not forget third- and fourth-party intruders (including insurance companies and administrators who push for productivity). The encroachment of these groups has put a strain on the original partnership.

One of the reasons I started this blog was to get back to the things about medicine that inspired me during my early years of training. I have had a relatively short career, so I am almost embarrassed to admit that there was a point shortly after residency that I felt I lost the meaning of being a physician. This was a time where I was seeing a large number of patients a day, not to mention all the other non-clinical –but just as crucial- work that was not built into the schedule and some life stressors that were going on at the time. There was no breathing room or bathroom breaks (and I am being literal about the latter, not the former). I believed that I was an empathic and capable physician, but I also knew that my interaction with patients was far from ideal during this time despite my best ability to stay afloat. Luckily, circumstances around scheduling patients changed in my office for unrelated reasons and things improved just enough for me to say to a clinic administrator “I am finally feeling like the doctor I have wanted to be.” Don’t get me wrong. I was still ridiculously busy, but not stressed to the point of physical, mental, and emotional exhaustion.

In some ways, physicians are functioning as skeletons of what they intended to be in our current healthcare system. I was a good example of this. I do not know any doctor who would not prefer to spend more time with their patients and be able to tap into their own empathic side. But the truth is that things like LDL goals, weekly visit numbers, and CPT codes are the measures that are valued because they are tangible and because practicing medicine in this country is still a business, after all, not a charity. So physicians working in cognitive specialties (like primary care) are trying to keep up with demand, working faster and smarter, pushing their neurons to the limits. How is this not going to translate into the interaction with patients?

Receiving sympathy from the general public is not my point here. What would be better is an understanding from both sides. So I cringe at comments and posts that pit doctors against patients. Patients do this. Doctors do this, too. And when doctors make certain negative comments online (mostly anonymously), I find it embarrassing to my profession. But I also know they do not do this out of malice. There is something seriously wrong with a system that turns a bright, well-intentioned, caring, and naively optimistic group into one that finger-points at the very people they aimed to heal.

I unknowingly embarked on a mini-mission to repair the doctor-patient relationship when I started to write this blog. My hope is to educate and inspire and to collaborate with others who have the same goals. As part of this mission, I am also hosting a movie event that is open to the public. It addresses some of the lesser-known aspects of practicing medicine that contribute to a physician’s burnout and will open your eyes to why some well-intentioned doctors are leaving the field. 

Remember, what both sides are really lamenting in our current healthcare system is the relationship that they hoped they would have. Ultimately, patients and doctors want the same things. We also both want this “marriage” to work and to have a long-lasting and mutually fulfilling partnership. With the right perspective from both sides and emphasis on the most important aspects of care -not the codes, visit numbers, or provision of unnecessary treatments and evaluations – it can be a win-win for both.

Advertisements

Zostavax now approved for people 50 years and older

Big news that just came out today:

Zostavax (the immunization that helps prevent shingles) was previously approved for people aged 60 and older. The FDA has broadened the eligible age range to include 50-59-year-olds. However, please note that many insurance companies have not even covered this immunization for 60+ year-olds, so patients would have to find out from their insurance plan whether this would be covered for them. It is not an inexpensive vaccination and not for everyone (depending on your underlying health condition). There have also been supply issues in the past, making it unavailable at times.

Elizabeth Taylor – humanitarian

Elizabeth Taylor died today.

In addition to acting, she was well-known for raising awareness and funds for AIDS, receiving the Jean Hersholt Humanitarian Award in 1993 for her work. I never had an opportunity to meet her, but I remember this lovely and striking work (at the Musée Nationale d’Arte Moderne – Centre Pompidou in Paris), which is the closest I got:

RIP to a legendary woman who tried to make the world a better place with her humanitarian work.

Music in Medicine: Not Just for the Surgeons

Earlier this month, I had a conversation with a family member about her observation that many physicians are musicians. A few days later, I encountered an interesting blog post by Rahul Parikh, MD entitled “The Truth about Music in the Operating Room,” which included interesting facts about the relationship between music and medicine. For example, there are studies that have shown more steady vital signs in doctors performing surgeries to music – even with rock music.

It seems obvious that the manual dexterity and discipline required of musicians would be requirements for surgeons, as well. As a musician, myself, I recall being drawn to procedural specialties during medical school. Once I had the unique opportunity to “open” a case with a gynecologist performing a laparoscopic tubal ligation because all of the residents were at a conference. My attending was closely monitoring me, of course, but the patient was in the good, steady hands of a pianist/clarinetist. Aside from the technical aspects, operations performed to music seemed to be associated with better communication, a calmer environment, and a greater sense of teamwork.  

Surgeons are not the only physicians who can benefit from music during the workday, although it seems they are the only ones afforded the ideal venue, with a “protected” space and time during their procedures. Listening to music while seeing 20+ patients a day is possible and not as distracting as one may think. What’s more, doing so might just keep a physician sane.

At one point, I had a small space in a room with both an ARNP and RN. Phone calls and conversations were very distracting. But I found that listening to music kept me focused on my tasks. (Other publications have referred to studies that corroborate this effect). Of course, I used earphones to keep from bothering my officemates, which probably reduced unnecessary interruptions, as well. Even if there is limited time, as little as two measures of a favorite melody can not only calm you, but reconnect you to your human side, the one most important to relating to your patients. Without that side, after all, it would be easy to function as a robot, seeing patient after patient after patient. It’s not for everyone, however. For example, physicians who do not regularly listen to or feel a particular benefit from music may be more distracted by it.

The true value of music is in the way it takes us outside of ourselves and our narrow minds and repetitive thoughts.  This is important during and outside of our workday. Music encourages creativity, calmness, inspiration, and productivity. What more can you ask for in the work environment? It even inspires me as I write this blog post….

Post-Tsunami Wound Infections

The recent earthquake and tsunami in Japan have raised concerns because of resulting radiation release by local nuclear power plants. As the country scrambles to protect its citizens by providing potassium iodide (which the thyroid would take up preferentially to the radioactive iodine) to its citizens, there are other health risks to keep in mind, as we learned from the Indian Ocean tsunami in December 2004.

Infections (particularly of the skin and soft tissue) are quite common in this type of natural disaster as a result of lacerations and even small abrasions from debris, which become contaminated with seawater, sweage, and soil. As international travelers return to their homes, it would be prudent to keep these in mind.

 Here is a brief breakdown of some of the organisms. Much of information is derived from an article in The Annals Academy of Medicine and was a good review of pathogens that we do not typically see on a day-to-day basis.  

Staphylococcus and Streptococcus (very common skin bacteria) should always be considered. Skin infections from these bacteria are very common, with or without any disaster. It is a common skin infection seen in regular medical practice.

 Aeromonas – This was the most common bacterial infection seen after the 2004 tsunami. It is a freshwater organism and, as many people rinse wounds in streams and rivers after skin injury, this can cause skin infections, as well. IMPORTANT POINT: the lab must be notified that you are looking for this specifically, as it involves a separate growth medium and protocol.

Pseudomonas – another freshwater bacteria that was quite common in the 2004 Tsunami

Mycobacteria marinum – A freshwater bacteria. Infection can be slow to develop and heal, cause minimal pain, but also can be difficult to treat. May require surgery.  

Vibrio vulnificus – This is a toxin-producing bacterium found in seawater. It can cause skin infections. This is a particularly serious infection for patients with diabetes or severe liver disease, with potential to cause septicemia (infection in the blood) and death.

C. tetani – This bacteria causes tetanus, which is an infection that has a high mortality rate and can occur with exposure to soil or the classic “rusty nail.” It can cause lock-jaw, spasms, and respiratory failure. It is PREVENTABLE. If you take anything away from this blog post, let it be this – stay updated on this shot (you should get this every 10 years. If you cannot remember when you got yours, ask your doctor if you would benefit from getting one, anyway).

Mucormycosis – a fungus found in soil that causes skin and soft tissues, as well, and generally requires specific antibiotics for treatment.

E. coli, Klebsiella, and Proteus are gram negative bacteria found in sewage or fecal matter. (These are also common causes of urinary tract infections.)

Rabies – This can occur due to animal bites during the chaos of natural disasters. There are regimens for rabies prophylaxis on the WHO website

The 2004 Tsunami also taught us that infections could be quite complex and multidrug-resistant. For example, there was a report in the NEJM of “Tsunami sinusitis,” which was caused by inhalation of seawater. The organisms found were Aeromonas, Klebsiella, E. coli, and Proteus.

In summary, the risk of skin infections risk is high after a tsunami. The list provided above is not exhaustive and not a substitute for your own clinical judgment. It is, however, a reminder of some of the more common organisms to keep in mind. It is likely an Infectious Disease specialist consultation would be warranted, as these cases can be quite complex. And don’t forget to keep current on your tetanus immunization.

A Letter to my Readers: An Inspiring Story

 

Dear readers,

At a time when there is so much bad news in the media, I came across this touching story. It speaks for itself, but for doctors, it is a humbling and rejuvenating reminder of exactly what role we play in the lives of others. For patients, it is a great story about giving back and gratefulness. There is much to inspire all of us. Because positive stories and optimism should be more infectious than the opposite, please share this story with others.

Thank you.

 -Linda

Certainty, Uncertainty, and How Patients Respond to Both

The Harvard Business Review recently presented an interview with Zakary Tomala, the author of a Stanford Business School study regarding certainty and uncertainty. The surprising finding? Experts are more persuasive when they’re less certain.

“The phenomenon at work here is what we call expectancy violations. People expect experts to be confident. Violations of that expectation surprise them. We see that in our data. Subjects reported being more surprised by the uncertain experts and the confident amateurs. A surprise draws you in and makes you pay more attention. It gives the review more impact.”

Tomala says that his study is one of the first to focus on “how one person’s certainty affects others.“ Although the study involved opinions about a restaurant, I started to wonder how the findings might apply to healthcare.

“When I went to the doctor, he said I was going to die in 3 months, and that was 2 years ago.” How many times have we heard this type of comment, one that seems to gloat at the failures of medical science? Growing up around religious people, I heard this a lot. At the time, I had feelings of relief and gratefulness when people I knew were able to beat the odds of their illnesses. But in the back of my mind, I wondered how a doctor would be able to claim such certainty. Or perhaps the patient misunderstood the doctor?

Medical training – mine, anyways – taught me that medicine is a lot grayer than we think. This was most clear in residency, and even more so when practicing. There are odds to everything. Expressing uncertainty as a physician can be difficult because patients today want to know things definitively. Most of the time, they come to us for answers, not opinions (even though a medical opinion is just that, albeit a very educated one, and often involves trial and error). Sometimes, we are pressed to answer questions that are impossible to answer with certainty. “How much longer do I have, doc?”

Perhaps part of the problem is that we shot ourselves in the foot when we had rapid advances in medical technology, which helped us diagnose and treat and make more of an impact on a person’s health. The perception of patients towards physicians and the self-perception of physicians themselves changed with the advances, as well. The we’ll-just-have-to-wait-and-see approach has been replaced by the let’s-get-to-the-bottom-of-this-ASAP approach. There is nothing wrong with this. We have benefitted more from these advances than the numbers can really tell us (think about loves ones treated for diseases that had dismal prognoses in the past).

Did American Healthcare get cocky? Did/do doctors presume that they had/have everything they needed to have the utmost certainty when treating a patient? In certain scenarios, if doctors project a particularly high level of confidence in a diagnosis or treatment and they are wrong, it can lead to distrust, doctor-shopping, and disjointed (read: expensive) care. There will always be cases where a patient found the diagnosis was in error and subsequently held that probably proficient doctor in lower regard.

I honestly do not know what goes on behind the closed doors of other doctor-patient evaluations. However, I do know that in my exam room words like “possibly,” “probably,” “I think”, “maybe,” “likely,” and “good chance” abound. I hope that’s what the patient hears, because that is the truth. Does that mean I am a bad doctor? Probably not.