Doc Season

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It may not be rabbit season or duck season but it definitely seems to be doc season, especially as the next version of the American Health Care Act is unveiled today. This (and the Affordable Care Act which preceded it) is not about patients — it is about how to keep doctors and the health care industry under reasonable cost control and maintain some semblance of quality service.

Physicians are lined up squarely in the gun sights of the media, government agencies and legislators, as well as our employers and coworkers, not to mention our own professional organizations, our Board Certifying bodies, and our dissatisfied patients, all happily acquiring hunting licenses in order to trade off taking aim. It’s not enough any more to wear a bullet proof white coat. It’s driving doctors to hang up their stethoscope much earlier than they expected just to get out of the line of fire. Depending on who is expressing an opinion, doctors are seen as overcompensated, demanding, whiny, too uncommitted, too over-committed, uncaring, egotistical, close-minded, inflexible, and especially, and most annoyingly – perpetually late.

One of the most frequent complaints expressed about doctors is their lack of sensitivity to the demands of their patients’ schedule. Doctors do run late and patients wait. And wait. And wait some more. Patients get angry while waiting and this is reflected in patient (dis)satisfaction surveys which are becoming one of the tools the industry uses to judge the quality of a physician’s work and character as well as their salary compensation.  It is considered basic Customer Service 101.

I admit I’m one of those late doctors. I don’t share the reasons why I’m late with my patients as I enter the exam room apologizing for my tardiness. Taking time to explain takes time away from the task at hand: taking care of the person sitting or lying in front of me. At that moment, they are the most important person in the world to me. More important than the six waiting to see me, more important than the several dozen emails and calls waiting to be returned, more important than the fact I missed lunch or need to go to the bathroom, more important even than the text message from my daughter from school or the worry I carry about my dying mother.

I’m a salaried doctor, just like more and more of my primary care colleagues these days, providing more patient care with fewer resources. I don’t earn more by seeing more patients. There is a work load that I’m expected to carry and my day doesn’t end until that work is done. Some days are typically a four patient an hour schedule, but most days my colleagues and I must work in extra patients triaged to us by careful nurse screeners, and there are only so many minutes that can be squeezed out of an hour so patients end up feeling the pinch. I really want to try to go over the list of concerns some patients bring in so they don’t need to return to clinic for another appointment, and I really do try to deal with the inevitable “oh, by the way” question when my hand is on the door knob. Anytime that happens, I run later in my schedule, but I see it as my mission to provide essential caring for the “most important person in the world” at that moment.

The patient who is angry about waiting for me to arrive in the exam room can’t know that I’m late because the previous patient just found out that her upset stomach was caused by an unplanned and unwanted pregnancy. Perhaps they might be more understanding if they knew that an earlier patient came in with severe self injury so deep it required repair. Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection is showing signs of a pulmonary embolism caused by oral contraceptives. Or the man with blood on the toilet paper after a bowel movement finding out he has sexually transmitted anal warts when he’s never disclosed he has sex with other men, or the woman with bloating whose examination reveals an ominous ovarian mass, or finding incidental needle tracks on arms during an evaluation for itchiness, which leads to a suspicion of undiagnosed chronic hepatitis.

Doctors running late are not being inconsiderate, selfish or insensitive to their patients’ needs. Quite the opposite. We strive to make our patients feel respected, listened to and cared for. Most days it is a challenge to do that well and stay on time. For those who say we are being greedy, so we need to see fewer patients, I respond that health care reform and salaried employment demands we see more patients in less time, not fewer patients in more time. The waiting will only get longer as more doctors hang up their stethoscopes rather than become a target of anger and resentment as every day becomes “doctor season.”

Patients need to bring a book or catch up on correspondence,  bring knitting, schedule for the first appointment of the day. They also need to bring along a dose of charitable grace when they see how crowded the waiting room is. It might help to know you are not alone in your worry and misery.

But your doctor and health care team is very alone, scrambling to do the very best healing they can in the time available.

I’m not hanging my stethoscope up anytime soon though some days I’m so weary by the end, I’m not sure my brain between the ear tips is still functioning. I don’t wear a bullet proof white coat since I refuse to be defensive. If it really is doctor season, I’ll just continue on apologizing as I walk into each exam room, my focus directed to the needs of the “most important person in the whole world.”

And that human being deserves every minute I can give them.

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Not Just Another Day

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“This is another day, O Lord…
If I am to stand up, help me to stand bravely.
If I am to sit still, help me to sit quietly.
If I am to lie low, help me to do it patiently.
And if I am to do nothing, let me do it gallantly.”
— Kathleen Norris citing the Book of Common Prayer

 

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This day is the wrap-up to my twenty-eighth academic year working as a college health physician,  the most demanding so far.  Despite budget challenges, inadequate staffing, a higher severity of illness in a patient population with burgeoning mental health needs,  our staff did an incredible job this year serving students and their families with the resources we do have.   Reaching this day today is poignant: we will miss the graduating students we have gotten to know so well over four or five years,  we watch others leave temporarily for the summer, some to far away places around the globe, and we weep for those who have failed out, given up or fallen away from those who care deeply about them, some never to return to school again.

In my work I strive to do what is needed when it is needed no matter what time of the day or night.  There are obviously times when I fall short– too vehement when I need to be quiet, too urgent and pressured when I need to be patient,  too anxious to do something/anything when it is best to courageously do nothing.  It is very difficult for any doctor to choose to do nothing but I vowed in my own graduation ceremony over forty years ago to “First do no harm.”  And I’ve tried hard to live up to that vow.

In a sense I graduate as well on this last day of the school year– only not with cap and gown and diploma in hand.  Each year I learn enough from each patient to fill volumes, as they speak of their struggles, their pain, their stories and sometimes hearing, most tragically, their forever silence.

I honor our students and their families on this day, sharing the blessings from us who work toward the goal of sending them healthier and better equipped and joyful into the rest of their lives.

It is not just another day.

 

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Music Against the Hard Edges

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In all the woods that day I was
the only living thing
fretful, exhausted, or unsure.
Giant fir and spruce and cedar trees
that had stood their ground
three hundred years
stretched in sunlight calmly
unimpressed by whatever
it was that held me
hunched and tense above the stream,
biting my nails, calculating all
my impossibilities.
Nor did the water pause
to reflect or enter into
my considerations.
It found its way
over and around a crowd
of rocks in easy flourishes,
in laughing evasions and
shifts in direction.
Nothing could slow it down for long.
It even made a little song
out of all the things
that got in its way,
a music against the hard edges
of whatever might interrupt its going.
~John Brehm “Passage”

 

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It may be that when we no longer know what to do
we have come to our real work,

and that when we no longer know which way to go
we have come to our real journey.

The mind that is not baffled is not employed.

The impeded stream is the one that sings.
~Wendell Berry “The Real Work”

 

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Who among us knows with certainty each morning
what we are meant to do that day
or where we are to go?
Or do we make our best guess by
putting one foot ahead of the other
until the day is done and it is time to rest.

For me, I wake baffled each day
that I am allowed
to eavesdrop on heartbeats,
touch tender bellies,
sew up broken skin,
listen to tearful stories
of those no longer wish to live
and those who never want to let go of life.

I wake humbled with commitment
to keep going even when too tired,
to offer care even when rejected.
to keep trying even if impeded.

It is only then I learn that
daily obstacles slow
but cannot stop
the offer of help,
the gift of caring,
the flow of time given freely
which overflows its banks with
uncertain certainty:
my real work and journey
through life.

May I wade in deep~
listening~
ready to raise my voice
for those who hurt
and sing along.

 

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The Mere Exception

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We should always endeavour to wonder at the permanent thing, not at the mere exception. We should be startled by the sun, and not by the eclipse. We should wonder less at the earthquake, and wonder more about the earth.
~ G.K. Chesterton

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As a physician, I’m trained to notice the exceptions – the human body equivalent of
an eclipse or an earthquake,
a wildfire or drought,
a hurricane or flood,
or a simple pothole.

Ordinarily I’m not particularly attentive to everything that is going well with the human body, instead concentrating on what is aberrant, out of control or could be made better.

This is unfortunate; there is much beauty and amazing design to behold in every person I meet, especially those with chronic illness who feel nothing is as it should be and feel despair and frustration at how their mind or body is aging, failing and faltering.

To counter this tendency to just find what’s wrong and needs fixing, I’ve learned over the years to talk out loud as I do physical assessments:
you have no concerning skin lesions,
your eardrums look just as they should,
your eyes react normally,
your tonsils look fine,
your thyroid feels smooth,
your lymph nodes are tiny,
your lungs are clear,
your heart sounds are perfect,
your belly exam is reassuring,
your reflexes are symmetrical,
your emotional response to this stress and your tears are completely understandable.

I also write messages meant to reassure:
your labs are in a typical range
or are getting better
or at least maintaining,
your xray shows no concerns,
or isn’t getting worse,
those medication side effects are to be expected and could go away.

I acknowledge what is working well before attempting to intervene in what is not.

I’m not sure how much difference it makes to my patient.
But it makes a difference to me to wonder first at who this whole patient is before I focus in on what is broken and what is causing such dis-ease.

I just might be astonished.

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A Furry, Finned or Feathered Treatment Plan

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Due to changes in Fair Housing Act laws, clinicians are experiencing a significant increase in requests from patients for medical documentation to keep emotional support animals with them in “no-pets policy” rental housing. On a college campus, this leads to far more than just two-legged mammals inhabiting dorm rooms.  There has been an animal explosion on our University campus with over seventy animals of various types approved as an “ESA” in the residence halls and unknown dozens more who live with their owners off campus yet still frequent campus.  Only a small minority of these animals are actually trained and certified as service animals with the right to accompany their owner on public transportation to any public place, including classrooms and eating establishments.  The rest are approved only for housing purposes, yet they are regularly showing up in airplane cabins and grocery stores, dressed in little jackets that are easily purchased along with “certification letters” for big prices on the internet.  ESAs have become part of the campus and community landscape.

As a relatively outdoorsy, green and tolerant northwest University campus, the presence of animals on our campus has yet to seem like a big deal, but as the animal numbers inevitably increase due to 25% of the college student population nationwide currently eligible for an animal due to a mental health diagnosis, it is becoming a big deal as individuals insist on exercising their civil rights along with their dogs.

And it isn’t always dogs.  There are cats, along with the occasional pocketed rat, hamster, guinea pig, flying squirrel, and ferret not to mention emotional support pot bellied pigs, tarantulas, and various types of birds.  And at least one snake.

Yes, a snake.

As a physician farmer concerned with stewardship of the patients I treat and the land and animals I care for, I’m emotionally caught and ethically bound in this treatment trend.  The law compels clinicians to provide the requested documentation to avoid  potential law suits alleging discrimination, yet I’m also concerned for the rights of the animals themselves.   I’ve loved, owned and cared for animals most of my sixty two years and certainly missed my pets during the thirteen years I was in college, medical school, residency and doing inner city work (my tropical fish and goldfish notwithstanding).  I neither had the time, the money, the space nor the inclination to keep an animal on a schedule and in an environment that I myself could barely tolerate, as stressed as I was.   That is not stopping the distressed college student of today from demanding they be able to keep their animals with them in their stress-mess.

As a clinician, I’d much prefer writing fewer pharmaceutical prescriptions and help individuals find non-medicinal ways to address their distress.   I’d like to see my patients develop coping skills to deal with the trouble that comes their way without falling apart, and the resilience to pick themselves up when they have been knocked down and feel broken.   I’d like to see them develop the inner strength that comes with maturity and experience and knowing that “this too will pass.”  I’d like individuals to see themselves as part of a diverse community and not a lone ranger of one, understanding that their actions have a ripple effect on those living, working, eating, riding and studying around them. Perhaps corporate work places, schools and universities should host a collaborative animal center with rotating dogs and cats from the local animal shelter, so those who wish to may have time with animals on their breaks without impacting others who aren’t animal fans, or with potentially life threatening animal dander allergies.

So I find myself reluctantly writing a prescription for a living breathing creature perceived by the law as a “treatment” rather than a profound responsibility that owners must take on for the lifetime of the animal.   With great gravity, I always let my patients know an animal is not disposable like a bottle of pills (or a human therapist) when no longer needed and must have a lifelong commitment from its owner beyond a particular time of high personal stress.

Pardon me now while I go take care of my dogs, my cats, by birds, and my horses and yes, my goldfish.  They are my joy to support for decades and for as long as they need me.

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A Z-Pack Pas De Deux

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I’ve been really miserable for three days and need that 5 day antibiotic to get better faster.

Ninety eight percent of the time these symptoms are due to a viral infection and will resolve without antibiotics.

But I can’t breathe and I can’t sleep.

You can use salt water rinses and a few days of decongestant nose spray to ease the congestion.

But my face feels like there is a blown up balloon inside.

Try applying a warm towel to your face.

And I’m feverish and having sweats at night.

Your temp is 99.2. You can use ibuprofen or acetominophen to help the feverish feeling.

But my snot is green.

That’s not unusual with viral upper respiratory infections.

And my teeth are starting to hurt and my ears are popping.

Let me know if that is not resolving in a week or so.

But I’m starting to cough.

Your lungs are clear so breathe steam, push fluids and prop up with an extra pillow.

But sometimes I cough to the point of gagging. Isn’t whooping cough going around?

Your illness doesn’t fit the timeline for pertussis.  You can consider using an over the counter cough suppressant.

But I always end up needing antibiotics. This is like my regular sinus infection thing.

There’s plenty of evidence they can do more harm than good.  They really aren’t indicated at this point in your illness and could have nasty side effects.

But I always get better faster with antibiotics. Doctors always give me antibiotics.

Studies show that two weeks later there is no significant difference in symptoms between those treated with antibiotics and those who did self-care without them.

But I have a really hard week coming up and I won’t be able to rest.

This could be your body’s way of saying that you need to evaluate your priorities.

But I just waited an hour to see you.

I really am sorry about the wait; we’re seeing a lot of sick people with this viral thing going around.

But I paid a $20 co-pay today for this visit.

We’re very appreciative of you paying promptly on the day of service.

But I can go down the street to the walk in clinic and for $130 they will write me an antibiotic prescription without making me feel guilty for asking.

I wouldn’t recommend taking unnecessary medication that can lead to bacterial resistance, side effects and allergic reactions. I truly believe you can be spared the expense, inconvenience and potential risk of taking something you don’t really need.

So that’s it?  Salt water rinses and wait it out?  That’s all you can offer?

Let me know if your symptoms are unresolved or worsening in the next week or so.

So you spent all that time in school just to tell people they don’t need medicine?

I believe I help people heal themselves and educate them about when they do need medicine and then facilitate appropriate treatment. 

I’m going to go find a real doctor who will listen to me.

A real doctor vows to first do no harm.  I know you want something different than I’m offering you and I wish you the best as you recover.

Let’s Put the Family Back in Family Medicine

Portrait by Norman Rockwell
Portrait by Norman Rockwell
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portrait by Norman Rockwell

An open letter to the American Board of Family Medicine (ABFM):

Yesterday I chose to sit for my sixth (and I hope final) Family Practice Board ten year Maintenance of Certification (MOC) examination, having now practiced as a Board Certified Family Physician for the past 34 years and intending to work a few more years. I want to share my experience taking this examination your organization prepares, promotes, and uses at high cost to determine which physicians meet the standards of Family Medicine, as stated on your website:

Family medicine is the medical specialty that provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system, and every disease entity. When you or a family member needs health care or medical treatment, you want a highly qualified doctor dedicated to providing outstanding care. When you choose a doctor who is board-certified, you can be confident he or she meets nationally recognized standards for education, knowledge, experience, and skills to provide high quality care in a specific medical specialty.

After my experience today, I am deeply disappointed in your vision of what a “highly qualified” Board Certified Family Physician needs to demonstrate on a MOC examination in order to meet “nationally recognized standards”.

As a medical student educated at the University of Washington during the early years of a newly organized family medicine specialty in the late seventies, I was inspired by the physicians who were our teachers and mentors in the art and science of caring not just for the individual, but their family system as well.  I then had the privilege of family practice residency training at one of the most progressive health maintenance organizations in the country (Group Health Cooperative in Seattle) where my teachers were not only excellent family physicians who were deeply involved with training residents, but actively involved in caring for their own patients as well. In addition, one of my best teachers at Group Health was a full time non-physician behavioral health specialist who taught us how to understand a patient’s experience of their illness and how an excellent family doc makes a difference in a patient’s sense of well-being.

As a result of those role models in my training and education, I have devoted my four decade career to family medicine in a variety of primary care roles — as a physician with a full spectrum practice in the inner city, as a director of a family planning clinic as well as a community health center for indigent and homeless patients, as an occupational health clinician for industry, as a community inpatient behavioral health and “detox” doctor for our local hospital, as a forensic examiner for hundreds of child sexual abuse evaluations, as a college health physician, and as an administrator. I have had the privilege to work with an immense variety of patients in diverse clinical settings, and only family medicine specialty training could have prepared me for that.

I believe in my specialty and the incredible versatility it offers to the physicians who choose it and to the patients who benefit from care by clinicians who are trained to work with the whole person, not just one aspect of their health.
I believe in those who practice a “womb to tomb” approach in providing continuity of care for an individual throughout their life cycle.
I believe in the opportunities within my specialty for some clinicians to concentrate only on certain aspects of patient care (geriatric care, palliative/hospice care, emergency medicine, hospitalist care, adolescent medicine, sports medicine, addiction care, behavioral health, etc)

I no longer believe, based on the contents of the MOC examination, the American Board of Family Medicine is living up to its commitment to its paying physician constituents. Board Certification is no longer an “option” for us but an economic necessity for our ongoing professional employment, credentialing and privileging.

First, I knew my preparation for this exam would need to be more rigorous than for previous exams as my current practice exclusively manages patients’ behavioral health issues given the current lack of psychiatric consultant availability or affordability.  As family physicians often do, we must step up and become the specialist our patients need when no other specialist is available.  I no longer see the full spectrum of life cycle medical issues so the many hours of review I did for the exam was necessary, extensive and time-consuming, even though I will not ever practice full spectrum family medicine again.

Second, the experience of taking the examination at a regional “testing center”  goes beyond standard airport security humiliation: having my eye glasses inspected in case they contained a camera, my wedding ring looked at, my pockets turned inside out, my sleeves pulled up, my ankles and socks uncovered,  being “wanded” for metal hidden on my body,  my wrist watch locked up with my purse and cell phone — this happened not just once but after every break, even to go to the bathroom.

Third, the exam itself in no way measured the diversity of skills required of an excellent family physician.   Over three hundred multiple choice questions each providing a few data and clinical points about a particular patient and based on that limited information, the test taker is asked to choose the “best” evidence-based treatment option or “most likely” diagnosis.  Absent are the nuances of patient demeanor in the exam room or how they respond on history-taking, the subtleties of a hands-on physical assessment. No information was provided about whether this particular patient has a family involved in their care, or what finances they have to afford the “best” treatment option when insurance won’t cover, or their willingness to comply with what is recommended.  A phone app could easily answer these exam questions with a search that takes less than twenty seconds yet our cell phones were taken away and locked up.  Your test content implies a family physician has to know all the details, the numbers, and the drug interactions committed to memory without the benefit of the technology tools we, along with many of our patients, use every day.

An excellent family physician can easily look up the “guidelines” and the “evidence based treatment” for a medical diagnosis, but beyond that must know how best to work with a particular patient given all the variables in their life impacting their health and well being.

Less than 5% of the exam questions dealt with any behavioral health issues when mental health concerns can be more than 50% of the issues brought to us in any given appointment.  There was minimal mention about the dynamics of family support, or insurance/financial stressors or relationship conflicts, or the many social justice issues impacting patient health.  There were no questions involving LGBTQ patients.  There were few questions about the impact of the current epidemic of substance abuse and addiction contributing to our patients’ premature deaths.  There was nothing that dealt with how to encourage and inspire patient compliance with our recommendations. There were no questions dealing with ethical decision making, or how to keep the computer screen from coming between the clinician and the patient, or how to maintain humanity in medical practice.

Fourth, I left that examination feeling very discouraged that the (all younger) family physicians who sat with me in that testing center are facing future years of this kind of superficial yet onerous assessment of their skills.  They are likely reluctant to “rock the boat” in questioning how our specialty has devolved to this but I am not.  I want to see this improve within my professional lifetime.

If the every ten year high stakes MOC examination were a surgery, an imaging study or a new medication, it would never pass muster for the ABFM standard of “best practice” and “evidence-based”.   That seems ironic for an exam that is designed specifically to measure physicians’ abilities to memorize and recall guidelines, best practices and what is recommended and what is not in certain clinical situations. Over my 30+ years of family medicine, many generally accepted and “evidence-based” medical practices have now been found to be ineffective, or at worse, harmful.  So we stop doing them and stop recommending them.

Yet somehow the high stakes MOC exam survives without evidence of benefit and one could argue causes significant harm including the immense cost in money, time and aggravation. I am not advocating for ceasing MOC, but want to see ABFM move on from the once a decade exam to a more frequent open book assessment — help us physicians learn more effectively and more eagerly.

I have worked at a University for three decades and understand the style of learning that results in information “sticking” versus that which is memorized and quickly forgotten, especially when it is not used on a regular basis. As Dr. Robert Centor has cogently commented about the MOC process, there is a difference between “formative” assessment of knowledge which is an ongoing monitoring of knowledge acquisition reflecting a learner’s strengths and weaknesses versus a “summative” assessment which is the high stakes end of the semester (or decade) examination.   We want our physicians to be enthusiastic ongoing learners with incentive to keep up on new medical innovation and knowledge.  To encourage that we need to launch frequent mandatory open book assessments of knowledge before more and more physicians drop out of the MOC process (and their practices) altogether.

I’m asking the ABFM and its Board members to not be tone deaf to the voices of physicians who are telling you “the emperor has no clothes” when we all have tried for decades to be good Board Certified citizens pretending that all is right and well with the process we are subjected to.

I’m also asking the ABFM and its Board members to reexamine the cost and need for security measures in a strip mall testing center setting which is the equivalent of MRI scanning 10,000 patients to find the one cancer  — this would never be an acceptable option on one of your exam questions.  Treat us as the professionals we are.

I know why I became a family physician over thirty years ago and it wasn’t to treat patients as demographic data points whose health parameters and decisions must meet “evidence-based outcome measures” so health care entities can be fully reimbursed for the work we do with them.

And so I ask you, on behalf of family physicians who don’t speak up, and on behalf of our patients:

~with your organization leading the way, let’s put the “family” back in family medicine.

~let’s put the doctor/patient relationship back in the forefront of the care we provide for people.

~and let’s stop meaningless multiple choice high stakes MOC examinations in strip mall testing centers and look at what really matters in Maintenance of Certification of family physicians.

Sincerely,

Emily Gibson, M.D.

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portrait by Norman Rockwell
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portrait by Norman Rockwell