It was a quiet year….

Two Thousand Thirteen was a quiet year for my blog. But it was a busy year of doctoring with 10-12 hours in clinic most days, an additional 2-3 at night, plus a few hours on most weekends. [We can analyze why over a drink sometime]. Of many sacrifices a full-time primary care practice necessitates, blogging was one of them. Also falling victim to the work schedule were guitar lessons, dinners with friends, and medical conferences I had planned to attend. Reading? Shopping? All of those seemed like luxuries. I missed writing on this blog, which was a nice way for me to reflect on this complex world of medicine.

However, in 2013, I did continue to work out regularly (for my own sanity, and – yes – I think of this as an achievement considering my schedule) and I wrote regularly for the Seattle Times as a columnist for the On Health section of the paper. I continued my position as a committee member with the Women in Medicine group of the Washington Chapter of American College of Physicians, and we hosted various increasingly successful events during the year. I continued to serve as an advisory board member for an IT company, learning more about the complexities of IT systems, networking, and EHRs. I mostly listened on Twitter, often inspired to write posts, but lacked the time and energy to put my best work into it. However, it was wonderful to keep up with some of writing of some of the colleagues I admire. And the best part of 2013 was that I had the honor of having one of my pieces published in a book (more on that in a future post).

We are fully into 2014 and New Years’ Day already feels like it was long ago. My schedule has not changed, but there is one thing I know for sure – this year won’t be so quiet for my blog.

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Vaccines and Public Health in the U.S.: We Need a (Celebrity) Hero.

“I was also fearful as a new mom but as a student of public health, I understand the evidence-based research now.”

– (author to be disclosed later in this post)

The above statement was made in reference to vaccines a little over a month ago… preBachmann. Michele Bachmann, as the reader likely is aware, is the Republican presidential candidate who broadcasted second-hand, anecdotal, unresearched, fear-mongering on national television on September 12, 2011. She did this by relating the story of a woman who had told Bachmann that her daughter developed “mental retardation” after receiving the HPV vaccination. The American Academy of Pediatrics made a statement the very next morning refuting any link.  It was a wise and necesarry move which seemed swift, yet quite possibly neither fast nor impactful enough.

Bachmann’s words were disheartening to doctors and public health advocates who were just beginning to see some light at the end of the vaccine controversy tunnel – a path that had been leading to new outbreaks of measles, which had been rarely seen in the last few decades. The February 2010 retraction of a Lancet article written by Andrew Wakefield (which had linked vaccines to autism) gave doctors more confidence and something more tangible with which to bolster vaccination recommendations. This is not to say there wasn’t enough evidence prior to that. However, a mere 587 days after the retraction of Wakefield’s article, vaccine proponents were dealt another blow with Bachmann’s story.

One would suspect that the vast majority – if not all – of graduating medical students understand and would emphasize the importance of vaccination. But with primary care doctors squeezed from every angle imaginable in today’s healthcare environment, taking the time to discuss vaccines with each and every patient can seem nearly impossible. In a way, it would seem that doctors who do not have the discussion of the benefits and risks of vaccines have also somehow lost the vision that their role as physicians includes understanding and meeting the needs of the “greater good” of society, as well.**

So, in times of pro-vaccination despair, who will take up the torch?

We need a hero.

The most obvious answer would be a celebrity. Dr. Kevin Pho concurs, stating in a recent blog post,

“Doctors are playing from behind, both with their job of ‘unscaring’ people and combating the celebrity-laden anti-vaccine movement. We need to get more politicians and celebrities onto the side of evidence-based medicine in order to reframe the vaccine debate.”

There is a celebrity who has historically been against vaccination. There are those who promote clean water. As alluded to in a previous blog post, it seemed unlikely that any celebrity would educate the public about the importance of vaccination as fervently.  Salma Hayek, to her credit, has worked with UNICEF and a diaper brand to promote tetanus vaccination in Africa. While there are certainly a lot of commendable and valuable global efforts and not enough for the immense need, vaccination against preventable diseases should continue to be emphasized here in the US.

So, to return to the comment at the very beginning of this blog post, the author is a public figure whom I have been following on Twitter for a few months. She is a well-known advocate for global maternal health and an internationally–recognized supermodel. Last month, I was excited to see that she had posted a couple of valuable tweets regarding the benefits of vaccination, including links to a relatively tame Penn and Teller skit and to an article in the LA Times.

This individual is clearly using knowledge from her public health studies to help spread the word about the importance of vaccines.  I wouldn’t want to put her on the spot as a definite “spokesperson” for vaccination, but I do admire her recent use of Twitter to address this very important issue.

The fact remains, we need a public health hero. Christy Turlington is willing to contribute. Is anyone else?

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(**Choice and informed decision making are very important in Western medicine. But the “informed” part needs to be just that – truly informed. Physicians need to educate, listen, and address concerns. Educate more. Then decide together.)

Never Let Them See You Sweat

One workday a few years ago, I had to be at a semi-formal family function by a certain time. Of course, of all clinic days, this one was even more hectic: multiple consultant phone calls, phone messages marked with “red flags,” letters that – for some reason – needed to be written on the day requested, and not one, but two people needed to go to the ER (one via ambulance). I drove as fast as legally possible to get to my relative’s house. Without having had a break to even go to the bathroom, it was difficult to sit in traffic. 

I got there eventually and was greeted with a slight reprimand for being late. OK. I expected that. But I didn’t expect the comment that followed. “What do doctors do, anyway? They spend just a few minutes with patients. Otherwise, all I see them do is talk to each other in the hallway.”

Leave it to family or close friends to push you off of your high horse (irrespective of whether you are on one or not). Not too long before this, there was a suggestion by an administrator of our clinic that we should increase the number of patients we see since recent changes in our EMR should have improved our efficiency. These two events made me wonder: Exactly how much time do I actually spend involved in patient care outside of seeing them? 

So, for the next few weeks, I used an online stopwatch and closely monitored my daily activities, recording how much time I spent on “indirect care,” including, but not limited to:
– refills
– patient questions on the phone
– phone messages
– reviewing consultant notes
– talking to consultants on the phone
– documenting/charting
– reviewing outside records
– filling out forms, including insurance authorizations and nursing home documents

(all of these tasks can require research into the respective patient’s chart)

Before you read on, if you are a patient, can you guess how much time this adds up to? If you are a physician, do you know exactly how much time this takes you? Have you ever tried to measure it? 

The answer for me:

4 to 4.5 hours a day. 

To clarify, I was the second most “efficient” physician in that moderate-sized practice, if not THE most efficient. And I was shocked by this number. I imagine that it would take 5-6 hours for docs who were not as efficient.

I do it despite the lack of reimbursement for the majority of these tasks. After all, it’s part of the overall care of my patients. You might not see such generosity, however, from other productivity-based-paper-pen-and-brain careers that lack fancy tools or equipment (accounting, law). What’s more, when nurses were phased out of primary care clinics, we lost some of the help with administrative tasks and some of the minor, more straightforward clinical work. Instead, primary care doctors were asked to “do more, in less time, with less help, and with less reimbursement.” It’s a part of medicine we often try to hide – rather than fix – and the part that medical students tend to avoid. That being said, I continue to practice in primary care because I still strongly believe in its purpose and I believe I am helping others… at least until a candid remark about physician “laziness” shocks me into the reality of a completely different perception out there.

While I work diligently to take care of other patients in between actual patient visits, I also work hard to give each person I physically see the amount of time needed to have him/her be heard and to be thorough. Though it sounds pseudo-therapeutic on some days, there is no such thing as a three-martini lunch, only a three-minute lunch. So, if I do happen to have the time to talk to a colleague, it is a nice reprieve. But twiddling my thumbs I most certainly am not. And, quite often, I think and worry about some of my sicker patients long after the clinic has closed….

By My Side

EMRs and iPads may come and go, but I can count on one thing. I realized this last week, when I walked into a couple exam rooms without it. I felt suddenly naked and out of sorts when I entered the exam room whitecoatless. Yet it was not the lack of uniform that flustered me, but rather something more important – believe it or not – than a CT or MRI. It assists my judgment and corroborates hypotheses in a few minutes. It makes the difference between life and death at times. It is often used to help confirm time of death, in fact. 

So basic and resilient is this trusty sidekick that I have underappreciated at times, having recently fallen under the spell of such things as healthcare communications and social media, iPads, and other expensive pursuits/gadgets. Perhaps a bit of technology and information overload has led me to suddenly appreciate the most “primitive” aspects of my profession, which have been so taken for granted that I was completely unaware of it’s unavailability in other countries

I speak, of course, of my stethoscope.

I got mine at the start of my focused medical training. Somehow, it was slim pickings at the medical school bookstore at the beginning of the year. I was left with one of a color that was less than appealing to me, thinking I would, perhaps, replace it when I became an attending. It was quite a steep purchase for a student living on loans and Rice-a-Roni. But it has given me MANY returns during our thirteen years together. And I have not swapped it out for another color (though I have contemplated adding some “bling” to it, ultimately scrapping the idea due to a realization that it would be quite a hassle to clean). 

My boring green stethoscope, in fact, has helped me through codes on the hospital wards, alerted me to carotid stenoses, confirmed suspicions of fluid on the lung, gave me evidence of pericarditis, and even doubled as a reflex hammer. In the age of expensive disposability, my stethoscope has only needed to have its earpieces replaced once. And I might have to do it once or twice more in my clinical lifetime. I do not even know if one of these things can actually be broken. It also has not yet been replaced by a flashy fad. Does anyone really need to upgrade their stethoscope?

My stethoscope is my constant companion, even when I am evaluating a rash. (You never know what you run into primary care, after all). It is the workhorse of medicine, undervalued and underappreciated, much like primary care today.