My Blog

MEDICAL OFFICES FACE A NEW HOLIDAY SEASON

Gone are the large tins of popcorn and the nuts. Ditto for the cookies and fruitcake. My practice administrator and I reflected last week about what our staff kitchen used to look like the week before Christmas ten years ago. The counters were overflowing with gift baskets, fruits, and all kind of holiday treats. The doctors’ desks had bottles of wine gifted by referring doctors and grateful patients. Now these areas are empty. Save for the few Christmas cards taped to the cabinet wall in the patient check out area, it would be easy to miss the traditional signs of the holiday season. Not even the hospitals are sending us gifts anymore. Why should they? They now seem to spend money buying up medical practices instead.

It is a fitting sign of our medical and economic times that the simple act of giving to one another to say “thank you for your loyalty and business,” is going the way of the “Walkman” cassette radio player. Perhaps it is our fear of government regulations and anti-kickback rules. Or maybe that we stand yet again on the precipice of the annual new century 25-30% Medicare pay cut due to SGR (Sustainable Growth Rate). As has become our yearly new tradition, we will write, call and email senators and congressmen pleading with them not to cut our Medicare rates….again. If the carrot doesn’t work, then we try the stick––if this passes, we will post signs stating that we can no longer afford to see new Medicare patients after January 1. If history repeats itself, there will be an eleventh hour repeal form the legislative executioner, as politicians suck up to seniors, cook the numbers and books, and miraculously put off the SGR cut for another year, adding another few billion dollars to our federal debt.

When medical doctors graduate they all recite the Hippocratic oath. Here is the second line: “To consider dear to me, as my parents, him who taught me this art, to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art, without charging a fee.” Many of us have interpreted this last line that we should also not charge our colleagues or families for our medical care, i.e. professional courtesy. Thanks to Congress, and in particular Representative Pete Starke of California, it is now illegal not to charge a colleague for medical care.

We used to give boxes of chocolates to nurses at the hospitals. This year we took the money we would have spent on that and gave our office employees a bonus instead.
Everyone it seems is cutting back––be it for legal or pure economic reasons. And yet something profound has been lost here. No I, and my waistline, do not miss the plethora of sweets and calories. What I believe is missing is simpler than that. It is gratitude. Thankfulness for our referring doctors, and from home health care agencies, patients, and oxygen supply companies. I cannot be bribed to send business to someone simply because they gave my office staff and me a large tin of popcorn.

What has been lost in this entire minefield of government regulations and compliance worries, is the death of giving to one another to show our appreciation. And that more than anything is what is missing from this holiday season.

A MIRACLE

Having practiced cardiology now for over thirty years, I have seen more than a few patients recover from open-heart surgery. However, until recently I had no direct experience with a child who had to endure similar trauma. Last December my granddaughter, in Atlanta, was born with a complex congenital heart malformation. She had a temporary procedure in February to keep her from being “blue”, or having low oxygen levels.  Although any “minor heart surgery” procedure is a bit of an oxymoron, she did well and was able to gain critical weight until a more extensive and corrective procedure could be done.

That procedure was done successfully on Friday, August 26, at Emory Children’s’ Hospital in Atlanta, and the parents were told to expect a one to two week hospital stay. The baby did so well that she was moved out of the intensive care unit after two days and sent home on only her third post-operative day. This is on the short end of the expected stay even for an adult undergoing coronary bypass and or valve surgery. To everyone’s surprise, this was nothing short of a miracle.

For my daughter who suffers with OCD, (Obsessive Compulsive Disorder), the hospital stay was a nightmare and she actually pushed for the early discharge. To her a hospital is a veritable house of horrors where mistakes are the rule, and every interaction with a healthcare person is fraught with errors in judgment and miscommunications. The blood must be drawn at 4 a.m.­­

“Why can’t they do it later?” she would ask.

“Because the doctors need this information early on to adjust medications before they enter surgery for another six to eight hours,” I answered.

The pre-operative echocardiogram took one and one-half hours.

“Why does it take this long?” she asked.

And I said, “You are in a teaching hospital, and everyone needs to learn. Complex congenital heart disease surgery is not done in community hospitals where things go faster.”

“Why do they have to awaken her for vital signs?”

“Because those are the rules,” I would say again, trying to be patient. Her baby was poked and prodded for 84 hours, and my daughter couldn’t escape this perceived medical jail soon enough.

Yet, what is easily over-looked here is the true miracle of rearranging the veins, arteries, holes, and valves of a sixteen-pound child in under three hours, and then discharged home in three and one-half days.

As a physician and cardiologist, it is not easy to be on the flip side of the doctor patient relationship. Nurses and doctors often dread taking care of a physician or his family, so I tried to be as unobtrusive as possible. However, the temptation often got the better of me as I asked the critical care unit nurse, “Is that right bundle branch block on her EKG new?” I think being on the receiving care of medicine, and or surgery, offers a wonderful opportunity to make us more compassionate and empathic caregivers.

The wonders of modern medicine, and the awesome skills of a pediatric cardiac surgeon are nothing short of miraculous. And oh by the way, the prayers of a multitude of friends and family members didn’t hurt either.

MAKING DOCTORS MORE HUMAN

Recently at lunch I sat with a general surgeon who I have known for many years. Like many of our peers, he is hard working and puts in many more than 40 hours of work each week. Before I decided to “slow down” a few years ago, my typical workweek was 60-80 hours. Dr. N, the surgeon, was lamenting about how things had changed and how new physicians did not share our same work ethic. He should know––his son is in training now to become a surgeon too.

“They don’t want to work as hard as we did,” he said. They realize they will make less money, but they want more time off for themselves and their family.”

“How can they do that and still practice good medicine?” I asked.

His response was simple and obvious––“Shift work.”

In the years since the two of us completed our training, the medical establishment has finally realized that putting in such grueling and long hours is not good for either the patient or the doctor. As an intern in the emergency room, I recall doing a two-month rotation of “24 on/24 off, meaning working non-stop for 24 hours, and then off for 24 hours. This pace was purportedly to prepare us for the rigors of private practice. It also weeded out those docs who would later enter a specialty with more humane hours like dermatology or pathology.

What it also accomplished was to wreck havoc on our personal lives and our marriages. Graduate medical educators finally realized there must be a better way to train doctors, and mandated maximum hours per week for interns and residents.

One of my lay friends asked why we cardiologists for example had to work such long hours. Being my patient as well as my friend, I tried to explain by example.

“Let’s say,” I told him, “that some night––like 3 AM, you have severe chest pain and go the ER––maybe you’re even having a heart attack. Who would you want to come in and see you?”

Without hesitation he said, “You, of course.”

“Well there you go, “ I said. “How good a decision maker do you think I’d be if I had just worked a 12 or 14 hour day?”

He of course had no answer.

I do believe that tired physicians make more errors, and in the end, these changes are probably for the better. It will however take some re-educating of patients to no longer expect their doctor to be there for them 24 hours a day, seven days a week.
A personal touch may be lost, but in the final analysis, this re-humanization of medicine will benefit everyone.

HYPERBOLE

Noun: An obvious and intentional exaggeration, or an extravagant statement or figure of speech not intended to be taken literally.

There are so many things vying for our attention these days that it is challenging to separate an urgent message from the ordinary or mundane. In our 24/7-news world with instant information delivered via texting, I Pads, and smart phones, we have become a community afflicted by collective ADD, (or attention deficit disorder). We can’t seem to get our fill of information, accurate or otherwise, which occurred only minutes ago, or in the case of Twitter, as it is even happening. If there is a natural disaster our first instinct is not to run to someone’s aid, but to record a video of it on our phones and then upload it to YouTube.

Consequently there is little, or no time, to evaluate the veracity of all this information. The same syndrome of over-hyping and glorification has similarly afflicted new medical information. Clinical trials of new treatments, medications, and procedural approaches to diseases, are released on-line before we have a chance to read them, let alone critically review the results.

Coffee is bad for you––no, wait––that’s old news. Now it is good for your heart and may prevent cancers. Vitamins and anti-oxidants were the darlings of the 1990’s, but now medical experts “know” they are worthless and just give us expensive “urine.”

Beer is bad for your weight and waistline. But news flash––it prevents osteoporosis, so drink up. Spicy foods make GERD (gatroesophogeal reflux disease) worse. Really?
Not according to most recent research. Now one of the culprits for this affliction is––(oh no, please tell me this isn’t true)––chocolate!

Finally, if I had a dollar for every time a newscaster, movie star, sports figure, or interviewee (of anything) says someone or something is “amazing” I could retire as a multi-millionaire tomorrow. If everything is so “amazing”, then nothing is left to be ordinary.

I suppose I should just get use to living in this age of exaggeration, embellishment and flash; but just for a while I’d like to turn back the clock, and watch a slow moving and boring world.

Seeing Clearly

Upon awakening this morning, I was able to see the clock on the wall, the neighbor across the street, and the television. It has been years since I was able to do this––at least without glasses. You see, on Thursday May 12, I had a cataract removed from my right eye, and a new corrective, or refractive lens, placed in the now empty eye capsule behind my cornea. The removal of the cataract, and placement of the lens was done under local anesthesia in about five minutes––nothing short of miraculous. It’s kind of like having a permanent contact lens inside your eye. My left eye, which I use for reading and intermediate distance––like looking at the computer screen as I am writing this, will be done in about two weeks.

For many people, this everyday ability of good vision is taken for granted. For me, it has been a life-long battle. When I was in second grade my mom figured I needed glasses when I was sitting about six inches from the TV screen. I wasn’t just a little nearsighted––I was half way towards legal blindness.

My eyeglasses looked like the bottom of Coke bottles, and I was constantly being teased as “four eyes.” When I graduated college, I celebrated the invention of contact lenses, even though they were the hard non-oxygen permeable type. I didn’t care––for eyeglasses-free living I would endure a lot.

As science advanced to more flexible, soft, and oxygen permeable lenses, my life too became easier––even as my near sightedness progressed. Upon hitting the age of forty, I could not read clearly without reading glasses, so it was back to frames and lenses for the new curse of farsightedness which comes with middle age.

I was able to buy a few years however with “mono-vision.” This is where your dominant eye, (in my case the right) is corrected for distance, and the non-dominant is under-corrected so you can still read and see the computer screen without glasses. However, by the time I was in my early fifties that stopped working too.

So next came LASIK, where your cornea is sculpted with a laser, so you purportedly don’t need glasses or contact lenses. Again, I went with the mono-vision, and again it worked-––at least for a few years. In 2005, my right eye suffered a plastic shrapnel injury when I stupidly tried to pry open a dresser draw, behind which my daughter’s cat was hiding. My right eye immediately went from 20/30 to 20/100 vision, and it was back to glasses––again.

I tired an enhancement of the LASIK in 2007 with an old procedure called PRK––forget what is stands for––it didn’t work. By 2010 my previously diagnosed cataracts had gotten so bad that I was afraid to drive a night.

Thus, the new chapter in my quest for near perfect vision continues. I will let you know how it turns out.

THE DARKER SIDE OF PROGRESS

I am not easily impressed with emails forward to me anymore.  However a recent one  called “The Truth” struck a cord with me, and is well worth repeating. There is a personal and societal price to pay for our faster and technologically advanced world. Yes, I can look up the price, dosage, and side effects of any medicine on my smart phone in less than one minute, whereas in years past I would have to search the voluminous pages of the PDR (Physicians’ Desk Reference).  Forgotten names and facts can be “googled” instantly, and we can scan bar codes in stores and check flights in progress on our phones or IPads. Yet, as technology has added so much to our “apparent” living, it also has distracted us from what is really important.

To quote from “The Truth”:

We have more conveniences, but less time.

We have more medicines, but less wellness.

We have learned how to make a living, but not live a life.

We’ve added years to our lives, but not life to our years.

We buy more but enjoy it all less.

We’ve learned to rush, but not to wait.

We have more kinds of food, but less nutrition.

We have more leisure time but less fun.

Spend more time with your family, friends, and loved ones. Life is a chain of moments to enjoy. Enjoy everyday, every hour, and every minute, for it may be your last and we never know when the end will come.

Sometimes we should stop waiting for that special day. Drink that special wine, or enjoy that special perfume now. Play hooky once in a while.

Yesterday is gone and tomorrow is only a dream––today is the only reality.

Think about it.

Trapped in Paper-Part Two

As I walk on to the floor of any hospital to see my ill patients, the search begins. If I am lucky, the patient’s chart that I need to review and write in will be in the correct spot in the chart rack. However, more often than not it, there will be an empty space––and then the hunt begins. First, I will look at the secretary’s desk to see if it is there awaiting orders, or perhaps another doctor has it in a back room, or a case manager, (formerly known as a social worker or discharge planner). If not there, then maybe a medical student or resident has it. If it is still missing, in frustration I will finally ask a nurse to help me locate it. . Names are no longer on the chart­––privacy violation––making the task even harder.  Sometimes they can’t find it either, and then I will finally go to the patient’s room. This is important since if the patient is in their room, the chart is somewhere on the floor, and the Easter egg-like hunt resumes. If they are gone, for example to the X-Ray department, then the chart is most likely with them.

Last month in this column, I lamented about the antiquated system of paper charts that still has most hospitals and physicians enslaved. Change is never easy. However, doctors as a rule are stubborn, and we fight the switch to the electronic health record (EHR) with all manners of gusto and conviction.

The EHR will happen no matter how much we wail or mourn for the past.  Part of the problem which makes the health care so system difficult to modernize to an e-record is that there are so many separate but interdependent parts: doctors, hospitals, patients, insurance companies, pharmacies, durable medical good suppliers, etc.  And then there is the always-tricky privacy concerns. Yet, these are solvable obstacles and should not be seen as insurmountable.

Here are a few of my suggestions:

• E-vendors need to do a better job of compatibility––records must be able to “talk” to each other.
• Hospitals should hire doctors to mentor their technically challenged colleagues.
• Set up realistic steps and timeframes, so the e-record is gradually phased in.
• Make sure there are enough working computers in all areas of the hospital.
• Seek input from nursing, secretarial, and physician staffs before foisting a cumbersome system upon them.
• After implementation dates, have technical staff readily available, even roving the halls, to help everyone.

It has been said that change is the only constant in life. The HER will come eventually, whether we like it or not. And I for one can’t wait, because a good portion of my day tomorrow will be hunting for charts––again.

TRAPPED IN PAPER

Suppose you walked up to a car rental counter, and instead of all your information going into a computer, you or the rental agent, wrote it down, then stuck it in a paper folder. You likely would move down the line to the next rental company.

As antiquated as that may sound, that is still what most patients face when they check in at a hospital or doctor’s office today. Despite the explosive growth in technology, where we can watch movies, access email, and bank on a smart phone, our health care system is still mired in a sea of paper charting and medical records.

A recent American Hospital Association survey found that less than one-third of our nations’ primary care doctors’ offices now have a functional electronic health record, or EHR. In fact, in 2010 another survey found that only 10 percent of office-based doctors had a fully functional HER system.

The statistics for hospitals is even worse. According to a report released in 2009 by the New England Journal of Medicine, just 1.5 percent of nonfederal hospitals in the United States use what was referred to as a “comprehensive” electronic health record system, meaning no paper chart––at all.

My cardiology practice went to a comprehensive EHR in 2004, yet we still produce lots of paper. If I order a blood test from a lab, or X-Ray from a local hospital, their computer systems usually do not “talk” with ours, and hence paper is generated. However, our office system is quite efficient compared to most hospitals, where multiple health care providers, from doctors to nurses to secretaries and physical therapists all vie for possession of a thick binder, where orders and notes and test results about one patient reside. The efficiency of this system versus an EHR, where everyone can simultaneously access vital medical information, is akin to a box filled with a large block of ice to keep foods fresh and cool versus a modern refrigerator and freezer.

Consumer surveys showed most Americans favor an EHR; however they are appropriately concerned about the privacy of their health information as well. I think these obstacles can be overcome. However, there has to be a high motivation between patients, physicians, insurance companies, and hospitals, to succeed. In a few weeks I will try and offer my suggestions about how this might come about.

Until then, I will spend most days drowning in paperwork and fighting a physical therapist, secretary, or other doctor over possession of a paper hospital chart.

He was much younger and shorter than I had envisioned him. The pediatric cardiac surgeon walked into the small consultation room only minutes after I had arrived, my coat and hat still in hand. It made my early 7:15 AM flight from Tampa worthwhile. As I sat with my daughter and son-in-law, he explained the operation just performed on my six-week-old granddaughter.

To reset this, I recently wrote about my daughter’s frustrations in dealing with multiple healthcare providers at a well-regarded university hospital in Atlanta. Her baby girl had been born with complex congenital heart disease, and answers to her many questions had been contradictory and inaccurate. Ultimately, after a multi-doctor conference, the surgeon elected to do a temporary, palliative operation, rather than a more complex definitive one, in hopes of the baby gaining more weight and having less congestive heart failure.

As I listened to him explain the operative findings, I felt reassured. He communicated well, answered all of our questions, and as his phone sounded, he quickly silenced it and refocused on our concerns and us.

So what had been the source of all the previous week’s confusion? Two things had conspired to hamper the doctor-patient-family lines of communication. First, one of the three surgeons was on vacation, making the already strained and limited surgical team busier than usual, and therefore not readily available to answer questions. Second, the pediatric cardiology staff kept offering opinions that were neither precise nor shared by the surgeon.

Yes, the baby’s weight was an issue, but no, there was no magical number of pounds as they had implied, before the definitive corrective surgery could be done. Our surgeon explained with her heart failure, she was burning up more calories trying to feed, than she took in, and when she was bigger, the curative surgery would be safer. Thus, he would temporize with a smaller operation to help her heart failure and have her gain weight. The surgery was performed successfully on Friday February 4, 2011, without heart-lung bypass, but required opening the breastbone, not a side incision, as again the cardiology staff had mistakenly told us. At the time of this writing, the patient is out of the intensive care unit and should be home in a few days.

The lesson here for me, and other doctors, is don’t give advice if you are not certain what you are saying is true and accurate. Patients and families hang on our every word, and more often are satisfied with “I don’t know,” or “you’ll have to wait and ask the surgeon,” than a physician who is guessing.

Finally, this scenario can, and does, occur in many hospitals. Due to the nature of a teaching hospital, communication amongst the staff is critical. A team leader needs to be identified to coordinate all of the various opinions, so that cogent and clear messages are delivered to families. If we can succeed in doing so, quality of care, as well as perception of care––not always the same––can only improve.