Dr. Jerkface In Context—Healing the Patient-Physician Relationship

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Excuse me, I took an unintended break for Thanksgiving!  Hope you all had a wonderful holiday!

NaBloPoMo 2017: Field Notes from a Life in Medicine

For the past year or so, maybe more, I have increasingly tried to engage my friends in discussion around allied advocacy for physician health and well-being.  Inevitably, however, I’m met with anecdotes from my friends about asshole doctors.  It is a strikingly common experience, I’m sad to report.  And it makes sense:  If a patient has a bad experience with a doctor, ie the doctor behaves badly or the patient feels dismissed, ignored, disrespected, or mistreated, the normal response is to blame the doctor and assume that s/he is an asshole.  In each of these interviews with friends, it took a while for them to come around to the idea that the doctor him/herself may be suffering and therefore not behaving/performing their best.

But the next question is this: Do patients care about doctors’ suffering?  If they knew how the system harms physicians, would they have compassion for us?  What about if they knew how physician burnout and dissatisfaction directly affects their quality of care, all of it negatively?  What would move patients to stand up with and for doctors?  This is my goal for the indefinite future: to help us, patients and physicians, the end users of our medical system, stand up with and for one another, for positive systems change.

Right now I see it as a very personal, grassroots endeavor.  Outside of a one-on-one patient-physician relationship, ‘patients’ and ‘physicians’ in general are abstract groups to us all, and it’s hard to feel compassion for and connection with an abstraction.  “Patients are too demanding, entitled, and ignorant.”  “Doctors are arrogant, dismissive, and profit-driven.”  We carry these overgeneralized internal narratives and others into our encounters, often unknowingly and unintentionally.  Even when we think we see and know the person right in front of us, these underlying assumptions still color our experiences with them.  So whatever conversations we may undertake will take many repetitions to finally reach true mutual understanding.

I have been a member of my church since 1991.  Many others in the community have been there much longer than that.  There are other physicians, and we are all patients, ranging in age from infants to octogenarians.  I have proposed to host a focus group to discuss patient-physician relationship, especially as it relates to the effects of physician burnout on patient care.  The plan is to do it once, with whomever is interested, and see what happens after that.  I picture 10-20 people, patients and physicians alike, seated in a circle.

The objectives will be stated:

  1. Hold an open discussion about people’s experiences in the patient-physician encounter, and explore the context of forces that influence those experiences. Such forces include visit duration, documentation requirements, workflow inefficiencies, patient expectations, insurance status, and clinical setting (hospital, outpatient clinic, etc.).
  2. Participants leave with improved mutual understanding of one another’s experiences in the medical system and more likely to feel empathy and compassion toward their counterparts in the next encounter.

In the long term, I wish for patients and physicians to form a unified platform from which to advocate for policy change.  We, patients and physicians, are the end-users of the healthcare system, the largest combined demographic in the system, and I believe we are the ones who benefit the least from the system.  Health outcomes for American patients are dismal compared other developed countries, despite our exorbitant expernditures.  Physicians kill ourselves at more than twice the rate of the general population.

It’s not enough for medical professional societies to write co-authored, open letters to Congress.  It’s not enough for individual patient constituents to stand up at town halls and berate their representatives.  We must orient ourselves as resistors in series, rather than in parallel.  I think the movement will grow most effectively out of existing connections and relationships, through which we can find shared interests, common goals, and a strong, unified voice for change.

I seek your feedback:

  1. How do you picture this meeting going?
  2. How interested are you in learning about physician burnout and how it affects patients?
  3. If you were invited to such a meeting, what would you think and feel about it?
  4. What would make you more likely to participate?
  5. Would you want to host such a meeting in your community? How would you do it?

Thank you for considering, and see you tomorrow!

Just Do It My Butt

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Happy late Monday, all!

Continuing my critical analysis of our American medical system…  This is not what I set out to do on November 1, I swear, and I have other more interesting prompts to expound on after today, I promise.  For now, thank you for indulging me in this rant of sorts:

My friend posted this article today, explaining how most methods of trying to get people to take their medications do not work.  It cited this meta-analysis, which concluded that “Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized.”  It also reviewed findings from another study, concluding that, “A compound intervention integrating wireless pill bottles, lottery-based incentives, and social support did not significantly improve medication adherence or vascular readmission outcomes for AMI [acute myocardial infarction—heart attack] survivors.”  The piece basically asserts that behavioral economics, or the art and science of ‘nudging,’ will not by itself heal what ails our behaviors, despite what Thaler and Sunstein suggest.

The discussion on my friend’s page then centered around ideas like motivational interviewing, coaching, and the like—methods that have been shown to improve likelihood of overcoming addiction, obesity, and other behavioral maladies.  It occurred to me that this is the best part of my work: asking the important questions to help patients identify meaning and intrinsic motivation for behavior change, and collaborating in such a way that they own the plan because they have an authentic hand in crafting it.   And even then it can take years for new, healthier habits to entrain, because we are complex beings each with myriad influences affecting our actions at any given time.  When I can sit and listen to what makes meaning for my patients (if they know—if they don’t then it can get really interesting or really not, it’s hit or miss), and talking about what the future might look and feel like with a few relevant changes, I bask in my professional heaven.

But who can actually do this in the modern American healthcare system??  It takes time, and as we all know, time is money.  It also takes training and resources.  We are not born knowing how to perform motivational interviewing and cognitive behavioral therapy, and even today, these skills are not necessarily mainstream medical school curriculum (well if we’re being honest, communication skills in general are still given short shrift, which boggles me).  Physicians can and do learn these skills. But they don’t necessarily have to.  Medical systems which include dieticians, exercise physiologists, and health psychologists can deploy these team members to support patients in their health journeys.  But does your doctor’s office have this kind of set up?  Does your insurance pay for these services?

Most likely the answer is no.  It’s shocking and dismaying, because this approach is proven to be successful in important ways.  I refer here to the Diabetes Prevention Program.  This study was published 15 years ago, on February 7, 2002, in the New England Journal of Medicine.  From the link, here is the study design summary:

“…Participants from 27 clinical centers around the United States were randomly divided into different treatment groups. The first group, called the lifestyle intervention group, received intensive training in diet, physical activity, and behavior modification. By eating less fat and fewer calories and exercising for a total of 150 minutes a week, they aimed to lose 7 percent of their body weight and maintain that loss.

“The second group took 850 mg of metformin twice a day. The third group received placebo pills instead of metformin. The metformin and placebo groups also received information about diet and exercise but no intensive motivational counseling.

“All 3,234 study participants were overweight and had prediabetes, which are well-known risk factors for the development of type 2 diabetes. In addition, 45 percent of the participants were from minority groups-African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, or Pacific Islander-at increased risk of developing diabetes.”

What do you think happened?

“Participants in the lifestyle intervention group-those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification-reduced their risk of developing diabetes by 58 percent. This finding was true across all participating ethnic groups and for both men and women. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. About 5 percent of the lifestyle intervention group developed diabetes each year during the study period, compared with 11 percent of those in the placebo group.

“Participants taking metformin reduced their risk of developing diabetes by 31 percent. Metformin was effective for both men and women, but it was least effective in people aged 45 and older. Metformin was most effective in people 25 to 44 years old and in those with a body mass index of 35 or higher, meaning they were at least 60 pounds overweight. About 7.8 percent of the metformin group developed diabetes each year during the study, compared with 11 percent of the group receiving the placebo.”

Lifestyle modification surpassed medication alone in preventing progression to overt diabetes in these high risk patients—almost double the benefit.  Well duh, you say, we all knew that.  We just need to eat less and move more.  But did these people ‘Just Do It?’  As if we can wake up one day and open a shiny new box of motivation that suddenly removes all of our circumstantial, emotional, and habitual barriers to optimal health?  No.  These patients were intensely supported by a dedicated, multidisciplinary team, day in and day out, for the long haul.  Every week patients reject my team’s offers to explore strategy for habit change, saying, “I know what I need to do, I just have to do it.”  Seriously, if it were that easy we’d all be doing it already (she screams as she pulls her hair out in knotted handfuls).

So, if this unequivocal study came out a decade and a half ago, why have we not implemented its procedure in primary care practices across the country?  I’ll wait while you think it over…

It’s money, of course, right?

It’s not that people in charge of healthcare spending don’t care about patients.  It’s that the financial returns of such an investment occur too far in the future to make for a good P&L calculation today.  Most insurance companies do not cover patients for the long run, so why should I expend all these resources to get you healthy today, so you can be healthy later and cost Medicare less many years from now?  The more I think about it, the more it makes sense to me to have a single payer system that can truly invest in our health, as a population of individuals, from birth to death.  And since habits and behaviors are established at very early stages of development, doesn’t it also make sense to have the medical/healthcare system integrated with the education system?  If we are a nation dedicated to the health and well-being of children so they can become healthy and well adults, why would we allow junk food in our schools and cut physical education?  What private, for-profit entity in its right capitalist mind would want to take that on?

Well, I trust you get my point.  It’s late and I have committed to writing every day this month, so I must stop here tonight.  Thank you again for your indulgence as I strode into the weeds on this one.

Hope to see you back tomorrow!

 

Eat What You Kill

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NaBloPoMo 2017: Field Notes from a Life in Medicine

Sounds like a mantra from a survival reality show, right?  Akin to “Eat or be Eaten,” “Kill or Be Killed.”  It’s also a common reference to the prevailing business model in our American scarcity-minded, competition-driven, fee-for-service healthcare culture.  How ironic, the application of these words to this profession.  It was explained to me essentially as, “Every man for himself, and you’re a minion.  You are expected to be ‘productive’ in this business to justify your compensation and contribute to the bottom line.  We measure productivity by number of patients seen and accompanying collections.  Pull your own weight or there will be consequences.”

Of course, from a capitalist business standpoint, this makes sense.  I provide a service that others require.  I should offer it widely, accommodate customer expectations and demands, expand my suite of offerings early and often, and charge for everything.  The more I can get customers to consume and pay, the better off my business.  I have a fundamental problem with this approach when the practice of medicine focuses on business first and patient care second.  Nobody admits to this attitude, of course it’s about patients first, everybody says.  Then my colleague makes a suggestion for patient care improvement, or I express concern about conveyor belt medicine burning doctors out.  Inevitably, the primary response from leadership is something along the lines of ‘that costs too much,’ and ‘that’s the only way to keep the lights on.’  I understand the math.  I despise the premise.

Medicine and healthcare delivery should always transcend the detached, transactional, and ruthless nature of the free market.  Chris Ladd, a conservative thinker and writer, describes this idea eloquently here.  It occurred to me today, replying to Stacey Holley’s comment on my post about spending time with patients, that even those who profit from our flawed American system are also terminally distressed by it.  Insurers, hospitals, pharmaceutical companies and their executives live in a constant state of fight-or-flight defensive posturing, fearing for their livelihoods in market share, revenue, solvency, and survival.  How tragically ironic.

Personally, I have difficulty envisioning a single-payer, government run healthcare program as the primary delivery system in the United States.  Our culture is simply far too individualistic, too fundamentally ingrained with ‘every man for himself.’  However, I think we can still work with the concept of universal healthcare, wherein all people have access to basic preventive and catastrophic care, regardless of income or status, without risk of bankruptcy.  A strong argument can be made that the only entity who could or should be truly invested in the health and well-being of all of us, throughout our lifespan, is our government, particularly in the realms of prevention and health maintenance.  We just need to loosen our societal grip on ‘that’s just how it works,’ and ‘I need to get mine,’ and allow ourselves to be led more by our collaborative, altruistic, and humanitarian leanings.  In my experience, diverse groups of intelligent and energetic people, working toward ambitious and aspirational goals, generate synergy.  This kind of cooperation fosters passion, joy, inspired creativity,  and magnificent innovation.  Who knows what novel solutions we may invent, if we only put down our spears and work together?  And isn’t that the hallmark of American ingenuity?

Medicine and health should be a heartening, collaborative, communal effort wherein we all do our best to help ourselves and each other reach our highest potential.  We are better than our current system, in which truly everybody suffers more than necessary.  I refuse to accept ‘Eat What You Kill’ as any kind of descriptor for my work or that of my colleagues.  We can do better, imagine and create more for ourselves and one another, than this primitive notion.  I know there’s a healthier mantra inside me somewhere…

What can you think of?

No Substitute for Time

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NaBloPoMo 2017: Field Notes From a Life in Medicine

Day 3

How much time do you spend with your doctor each time you see them?  Is it enough?  If they had more time to spend with you, how would you use it?  Would it be better?

I’m too tired and it’s too late tonight to discuss the myriad factors that erode the patient-physician relationship, and thus our medical system in general.  But time comes to mind often for me, and I wonder if patients are as frustrated about it as I am.

Where I work now, I pretty much have as much time as I want with people.  It’s a sweet gig.  I can ask them about their work, their families, their interests.  I have time to listen to the answers, and even connect those with my observations about their health.  The most interesting parts of my interviews are the social history.  What do they spend their days doing at work?  What problems do they solve, who do they interact with, and what brings them meaning at the place where they spend the majority of waking weekday hours?  Then what do they do for fun, what’s life like outside of work?  I get to know my patients as individual, whole people, which I love, and that makes me look forward to every day at work with joy.

But time is not just good for me, for my professional fulfillment.   It’s good for patients, too.  When I spend time asking the important questions, putting together pieces of a person’s symptom puzzle, and do a directed exam, I’m more likely to come to a correct diagnosis and make an appropriate and specific care plan.  When I take the time to explain my rationale, decision process, and possible outcomes and follow up, my patients are more likely to feel seen, heard, and reassured.  They are more likely to stick with the plan and contact me if things change.  The next time they need help, they are more likely to call me and we have another chance to know each other better.

When the physician-patient relationship flourishes, we’re all healthier.

I love this article on The Health Care Blog, which essentially validates the time I take to talk to my patients.  My favorite line:  “More information about the value of a physician-patient encounter will always be found in the content of their communication than in what they ultimately do. The difference in… physicians’ behaviors will not be found in any database, electronic medical record, or machine-learning algorithm. I have yet to see data on the contextual information from a history of the present illness in any data set or quality improvement initiative.”

You may also be interested in this article, describing the origin of the 15 minute clinic visit, and why it really doesn’t make sense.

What do you think about physicians and patients advocating together to change this aspect of our flawed medical system? I know it’s complicated, requiring a hard look at our billing and compensation processes, as well as our productivity-driven, fee-for-service medical culture.  I still think it’s worth pursuing.  There is no substitute for time.  We must protect and defend it; our health depends on it.

Resistors In Series

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As nerd stuff goes, biology has always been more my speed than physics.  When my group in AP bio got to dissect a fresh frozen elk heart instead of a preserved sheep heart, I was positively overjoyed.  I remember so clearly the size (almost as big as my head) and weight of it, the texture of the muscle.  I can still see the valves, the heartstrings, and coagulated blood in the right and left atria.  So it kind of surprised me when I thought of a physics metaphor for our politics today.  I, the daughter of a PhD in applied mechanics, earned the lowest grade of my college career in first quarter physics.

Like many science nerd adolescents of the 80’s, I looked forward to new episodes of “MacGyver” every week.  The handsome, mullet-sporting Richard Dean Anderson always jerry-rigged his way out of life-threatening situations using everyday chemistry and such.  How fun that my kids can now enjoy the same drama with the CBS “MacGyver” reboot, starring Lucas Till.  We bond over TV, my kids and I.

macgyver white board

In the “Chisel” episode, Mac and his team find themselves barricaded inside a US Embassy, under attack by terrorists.  On a white board, he calculates how many inches of paper to place in front of the windows to stop incoming machine gun bullets—it’s 8 in this case.  [As an aside, the Mythbusters showed that paper is a plausible form of body armor.]  This got me thinking: one sheet of paper, so thin and flimsy, is easily shredded.  But layered in redundance, it can stop a barrage of deadly bullets.  It feels a lot like our national political activism since last November.

Women, scientists, environmentalists, educators, people of color, the LGBTQ community, Native Americans, writers, actors, physicians, patients, religious groups, law enforcement, legislators, and the press—We have all found our legs and our voices; we have stood and proclaimed not only our opposition to 45, but our commitment to our core values of inclusion, equality, respect for the planet, and respect for one another.  I submit that we are resistors in series.

resistors in seriesYou may recall from physics class that when resistors are placed end to end in an electrical circuit, their total resistance is the sum of their individual impedance units.  As the current passes through one resistor, it encounters the next one, and the next, one after another, slowing its progress.  I like to see today’s activist groups in this way, each contributing several layers to the dense, thick paper barricade at the windows of democracy as we know it, defending it against attack.  And the more we can stand united, supporting one another, the stronger we will be.  Could our resistance even be exponential, rather than simply additive?

Tyrants and authoritarians divide to conquer–they like resistors in parallel, where the total impedance is actually a fraction of each individual unit’s resistance.  By pitting each group against every other, a despot can trample them each/all with ease, and they might never see it coming—the same voltage directed across multiple, isolated resistors transforms them into conductors of the oppressor’s will.resistors in parallel

Perhaps this was our orientation prior to the last election.  We each had our pet causes, for which we felt varying degrees of personal activism.  We saw ourselves as detached, benignly unconnected.  But as we have witnessed a progressive threat marching against everything that we care about, a shared, collective threat, a new current has sparked.  Perhaps this mutual unease has reorganized us to connect in succession, to close ranks.

I was reminded of this idea when I read this piece by Charles M. Blow in the New York Times.  He posits that “America regularly experiences bouts of regression, but fortunately, it is in those regressive periods that some of our greatest movements and greatest voices… found their footing.”  Then I came across another article from The Atlantic, suggesting that even our legislators may be reorienting themselves into more serial, additive connectedness:

In hindsight, the Democrats’ decision to not allow partisanship to subsume collegiality or compassion, to cheer McCain along with their Republican colleagues, to embrace a friend even as he cast a decisive vote to move forward with a bill they despised, no longer seems naive. “I hope we can again rely on humility, on our need to cooperate, on our dependence on each other to learn how to trust each other again and by so doing better serve the people who elected us,” McCain had said in his speech.  

Had Democrats met that vote by attacking McCain, he might not have voted no [on the Senate’s ‘skinny repeal’ of the Affordable Care Act] last night. He might not have been so immune to the entreaties of his colleagues. He might not have resisted the arm-twisting of the president who never spent a day in public service before winning an election, who mocked him so cruelly two years ago. He might have decided against casting a vote to derail his own party’s seven-year crusade to dismantle the Affordable Care Act, a goal he still endorses.

I know my analogy vastly oversimplifies our political landscape.  Still, it comforts me.  I feel particularly focused on healthcare today, and I like to think that even if healthcare is not someone else’s chief concern, she will stand up with me when our healthcare system is under attack, just like I will rise with her in defense of our natural treasures, etc.  We stand, shoulder to shoulder, hand in hand, to resist and defend.  This vision of unity and cohesion is my hope and aspiration, not just now, but for generations to come.

Innocence, Indignation, and Idealism:  An Optimist’s Reconciliation

I took my daughter to see “Wonder Woman” last weekend.  I highly recommend it—such a strong, complex, and inspiring portrayal of humanity at its best and worst, with a hopeful ending.

Today I’m (somewhat) inspired in parallel by (some) politicians, three Republican senators in particular, calling for transparency in drafting healthcare reform.  I hereby present my attempt to integrate that exquisite Wonder Woman Experience with my current political outlook.

***WARNING*** THIS POST MAY CONTAIN SPOILERS FOR THOSE WHO HAVE NOT SEEN THE MOVIE.

Innocence

Diana of Themyscira grows up believing in the innate goodness of humans.  The Amazons are educated, independent, strong, and proud, and also collaborative, compassionate, kind, and sensitive.  When Diana learns of the horrific war waged by mankind outside of her paradise home, she relates it to the story of Ares, the God of War, who corrupts the hearts of men to commit acts of hatred upon one another.  So, naturally, she sets out to kill Ares and fix it.

We journey with Diana through challenge and triumph, as she learns that, of course, it’s not that simple.  She kills the man she thought was Ares, and nothing changes, the war rages on.  She must reconcile the possibility that the heart of mankind is not actually pure goodness.  Even without an insidiously corrupting God of War, humans are prone to their own malignant beliefs and actions.  Her innocence is pierced.

In the summer of 2009 or 2010, my best friend from college and his wife came to visit.  He, a molecular biology and political science double major and emergency medicine physician, and she, a worldly intellectual and future legal counsel for a major media outlet, were the first to burst my innocent political bubble.  For some reason, likely due to the tremendous inspiration of Barack Obama, I had gone from thinking all politicians were liars and performance artists, to seeing them as genuine public servants, working to advance their authentic ideas of how society functions better for all citizens.  I know, La-La Land!  My friends described an alternative, more realistic path to politics: Person succeeds at business, rubs elbows with regulators and influences them (with money or otherwise) to facilitate his/her business success.  Said person then realizes s/he could actually become one of those regulators and make a more permanent positive impact on these business interests, and so runs for office.  I still remember how deflated I felt, shoulders slumped, spine rounded, at this sudden and stark realization.

Indignation

As with everything, I’m sure political reality lies somewhere in the messy middle between pure altruism and blatant, self-serving avarice.  But these days, for someone who loved Obama and almost everything he stood for, it’s hard not to see the whole of our current political landscape as the latter.  I think, Really, WTF?  Can those in power really see nothing valid whatsoever in anything accomplished the past 8 years?  Do they really think that see-saw policy-making, each administration reversing everything from the previous one, replacing wise, experienced public servants with ignorant neophytes (my opinion), is the best way to govern?  OMFG, you have got to be kidding me.  I seethe.  But what can I do?

Ares reveals himself, and taunts Diana in her most vulnerable moment with his arrogant disdain for man’s weakness and corruptibility.  He also reveals that she is, in fact, the only one who can vanquish him—only a god can kill another god.  Diana, daughter of Zeus himself, possesses the power to Kick. His. Ass.  Yet he dismisses her out of hand, oblivious to her inner strength of conviction and compassion (I know, so much to expound on here, maybe in another post!).  Nope.  Righteous indignation rises.  She digs deep, finds that core courage, and obliterates him.  Fist pump.  He never saw it coming.

Idealism

In the end, Diana realizes that humans are a paradox: a big jumble of contradictions, perpetrators of horrific rage and destruction, and also fully worthy of love, forgiveness, and compassion.  She somehow finds peace in this enigma, loving the best of humanity and vowing to protect us against our worst selves, helping us to become better.

This resonates with the idealist in me.  This is how she helps us, and how we can help ourselves.

How Can We Help?

We can choose to fight against one another, and thereby focus on what we hate (about ourselves).

Or, we can choose to seek the good in one another, and focus on what we love— even better, focus on love itself.  We all want access to healthcare, and to be free from bankrupting medical expenses.  Everybody wants to be safe from gun violence.  We all want an efficient government that sets reasonable regulations, protects citizens’ constitutional rights, and spends money wisely and with accountability.  We all want to feel protected and free, loved and free to love.

The messy middle is the how.  That is where we negotiate.  That is also where the magic happens, as Brené Brown says, and that is where we must go, where we must persist.  We can bring our best selves to meet others’ best, in mutual respect.  It can be high risk, so we can enter slowly, strategically, with realistic expectations and a few trusted friends.

To this end, I will continue to seek out and hold up elected officials who call for more thoughtful political processes.  My friend Triffany and I have made a habit of writing thank you notes to Members of Congress to validate their cooperative acts.  We harbor no illusions about purity of intent, but we also know that positive reinforcement works.  We can be Diana to anybody’s Ares.

Focus on and fight for what we love: common goals and interests, shared humanity, connection, and one another.  It’s a lifetime’s worth of work, and well worth the fruits, if we can stick with it.

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On Shared Advocacy

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NaBloPoMo 2016, Letters to Patients, Day 14

To Patients Concerned About the Future of Healthcare:

We need one another now more than ever.

In April last year I started this blog to help patients and physicians connect in an increasingly disconnected healthcare system.  Both patients and physicians feel bound and invaded from multiple directions, all interfering with the doctor-patient relationship.  We all suffer for it.

It occurs to me that many of you may not know exactly what we physicians struggle with, that makes some of us so grumpy every day.

What assumptions do you make about us, and how does that impact our interactions?

Here are just a few of our challenges:

Electronic Health Record.  You’d think this would make everything faster, easier.  It has not.  It’s not only your chart.  It’s your billing record.  It’s the demographic, biometric, diagnosis, treatment, and outcome data repository.  And it’s clumsy, to say the least, at all of its functions.  Read more about how it negatively impacts physicians’ quality of life and care here.

Quality Measures.  We all want you to have the best quality care possible.  But how do we measure that?  Many payers base it on outcomes.  Physicians are judged and compensated, for instance, based on their patients’ blood pressure, blood sugar, and whether or not they have quit smoking.  But I cannot control these things.  I cannot make you take your medication or stop eating sugar.  I cannot make you stop smoking.  What I need is to talk to you about your life, so we can figure out the solutions.

Quantity pressure.  But talking requires time—quality time.  The 15 minute clinic slot is designed to maximize volume, not quality (how ironic?).  If you have an acute problem, on top of your uncontrolled blood pressure and diabetes, and we also have to set up your mammogram and colonoscopy, how can I possibly have time to explore, let alone address, the nuances of your health behaviors?

Some of my colleagues advocate for policy change at state and federal levels.  When I suggest that we consider bringing patients on board to help advocate for/with us, some eschew the idea.  We advocate for our patients, not the other way around, they say.  It’s as if we will be seen as weak that we bring you along to speak on our behalf.

The way I see it, we should all stand and speak up for one another.  Yes, in our working relationship I have more power and authority in many ways, and it’s my job to take care of you.  But we are all participants in the larger system, and I think we can make greater, faster change for the better if we all fully understand our shared interests and goals, and advocate for them side by side.

What else do you need to know?

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*For your information, here is an excellent article describing the movement toward integrating physician health into healthcare policy for the benefit of all.