Tuesday, February 22, 2011

Doctors don't get snow days

We received 8 new inches of snow overnight, and I readily admit to a wave of nostalgia this morning as the radio mentioned the prominent local school closings. 

Remember snow days?

My childhood snow days started with a portable radio next to my ear in bed.  Back in the pre-internet days, I'd listen with increasing anticipation as the radio D.J. read down the entire alphabetic list of school closings.  With any decent storm, after the "J"s, but before the "L"s, would come "Kettering," my district, and I'd turn off the radio and blissfully drift off into another hour or two of sleep.

My siblings and I would often be treated to a full breakfast on those mornings, a special treat during the week.  Since my mother worked in education, she'd usually be off for the snow day as well, and we'd feast on French toast or pancakes.  Then came a full day of romping in the snow, mindless television, time to curl up with a book, maybe even a board game.  Unlike weekends, which were often filled with sports and church activities, a snow day was complete, unfettered leisure. 

Now, of course, my snow days are over.  Patients need care at all hours of every day - on holidays, in the middle of the night, and when the snow falls.  I was on call when Snowmageddon hit last year, and I had to battle barely plowed roads and fallen trees to get to the hospital.  

Ah, if only to have a snow day again. 

Thursday, February 17, 2011

The high stakes of those conversations about flu shots

The first patient on the residents' schedule today was a child febrile to 102 F with cough and malaise.  The clinical picture strongly suggested influenza infection, especially in the setting of spiking flu rates in our area.  The resident looked through the chart and found that the family declined influenza vaccination here last fall.

It is a story that I have heard so many times already in my career, and one that I fear I will continue to hear.  I spend the fall months imploring people to vaccinate themselves and their families.  I answer the same questions over and over again: "No, the flu shot cannot give you flu.  It's just bits and pieces of dead virus."  "Yes, the flu shot can make some people feel mildly ill for a day or two.  That's just your body's response to the vaccine doing its job." 

Then late winter arrives (last season's H1N1 pandemic notwithstanding), and we are confronted with the misery of our patients who suffer terribly from influenza.  And, honestly, at least for me, the compassion for these patients comes mingled with frustration.

I certainly understand why our patients are declining vaccination for influenza.  They are barraged by media messages that inconsistently fall on the side of science and reason.  Googling "influenza shot" brings plenty of reputable sites, but, also, several that trumpet anecdotal tales of woe blamed on the flu shot. Over 50% of healthcare workers don't get flu shots for themselves. (1)  No wonder patients doubt the safety and/or necessity of influenza vaccination.

My frustration arrives when patients seem more inclined to believe all of those messages over their family doctors.  Why doesn't the "MD" after my name carry more weight?  Why don't more people heed the repeated calls from a myriad of organizations for vaccination?  Has the public lost faith in our profession?

Meanwhile, my public health training reminds me to look at the bigger picture.  Tens of thousands of Americans will die from influenza and its complications this year. (2)  Those numbers remind me that the goal of regaining our patients' trust is not ultimately about us; it's about saving lives. I cannot succumb to frustration, lose patience with answering those questions, and give up my persuasive efforts. The stakes are too high.
I only wish that the consequences of that failed persuasion didn't include the suffering of a child from a potentially preventable illness.

(1) Mitchell D.  "Poor Flu Vaccination Rates Among Health Care Workers Imperil Patients, Colleagues."  AAFP News Now.  August 4, 2009.  http://www.aafp.org/online/en/home/publications/news/news-now/vaccine/20090804hc-workers.html  accessed 2-17-11.

(2) Because the spectrum of influenza is highly variable from season to season, annual death rates have varied greatly over the last 50 years.  The current estimate of the average deaths expected in one year is 25,000.  "Estimating Seasonal Influenza-Associated Deaths in the United States: CDC Study Confirms Variability of Flu."  http://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm accessed 2-17-11.

Thursday, February 10, 2011

Doctors get sick, too

When I treat my patients, I typically start by stating my compassion for what ails them.  Migraine headache?  "Oh, that sounds awful."  Ankle sprain?  "How frustrating!"  Venous insufficiency?  "I'm sorry to hear that."  We teach our residents and students that validating our patients' symptoms is of critical importance.  Unless our patients feel that we truly hear and connect with them, they cannot enter into the patient-provider relationship with trust.  No trust = no ability to problem-solve together.

But, deep down inside, I distance myself from any real, visceral connection to my patients' symptoms.  I need that space to think objectively and to protect the core of my emotional self.  If I had to constantly experience the agony of a migraine, the throb of a sprain, the ache of lower extremity edema, I probably couldn't survive in this occupation for long. 

Sometimes, though, life rudely reminds me that I am just as vulnerable as my patients.  The most recent episode of this rudeness hit at about 1:30 am this past Monday morning, when I awakened in a cold sweat with gut-wrenching nausea.

By about 5:00 am, it became clear that I wasn't going to make it into work.  I suspect that I am not too different from most doctors in that I hate, really hate, to call off work.  And, like most docs, I'll work through just about any ailment, even ailments that I would encourage my patients with to "take a couple days off and rest."

I was helpless, however, in the face of mid-winter's viral GI hell.

As an academic family doctor, calling off means rescheduling meetings, connections that might have been months in the making.  It means finding coverage for teaching responsibilities, burdening my colleagues with unanticipated duties.  And, worst of all, it means rescheduling patients, individuals who might have been depending on that appointment to bring them some relief from their own concerns.

On the other hand, it did serve as a good reminder of my non-essential-ness.  Now back at work, it's pretty clear that everything hummed along without me just fine.  The office staff rescheduled my patients.  My colleagues covered my teaching.  The meetings found new times.  It's honestly a bit of a relief to remember that the world does not rest squarely on my shoulders alone.

Along with that relief comes a heaping dose of humility.  Shame on me, for thinking that I'm so important and invulnerable!  It's easy to lose perspective, sometimes, in this slightly surreal world of academia where nothing is ever truly "done" and new challenges always beckon.  I just wish that I might have gained a reminder of that perspective in a slightly less, uh, unpleasant way. 

Ah, well.  Lesson re-learned.  Anyone else want some ginger ale?

Wednesday, February 2, 2011

A (wet) 1950s pager in a 2011 world

I've done it a few times.  First, when I was a third-year medical student.  Then again when I was an intern, and again as a third-year resident.  Well, I haven't done it since residency and thought those days were over....but then I did it again today.  Dropped my pager into the toilet.


I will leave to your imagination my verbal response to seeing my pager cruise gracelessly into the toilet bowl.  I fished it out, frantically popped out the battery, and rushed it to the sink.

I lovingly patted the pager dry with paper towels.  I frantically shook it to try and coax the water to dribble out.  But the streams of water continued to slosh around between the plastic cover and the green screen.

I drudged up the steps to our Telecommunications office, dreading having to relay this rather humiliating story.

"May I help you?"  asked the perky operator.

"Um, my pager got wet."  I didn't make eye contact as I handed it to him.

"Oooh, got the screen.  It's done for." 

I silently thanked him for not asking precisely how it got wet.

"Here you go."  I accepted the new pager and clipped it on my waist.  "Have a good day, doctor."

Am I fundamentally irresponsible, to have sent so many pagers on an unintentional swimming trip?  Or are fat, bulky pagers prone to hurdling off a slouched white coat pocket (or a dropped pair of pants) an antiquity in an age of iPod nanos?

Wikipedia has a cool link in its reference section to the very first pager, introduced in 1950.  (http://en.wikipedia.org/wiki/Pager #2 in reference section)  Let's just say that they haven't changed much since then.  Certainly the fundamental functioning of pagers hasn't needed much of an update, but what about the physical design?  Why do pagers in 2011 look nearly identical to those from 1950?  I can't think of too many technologies I could say that about.  Surely a sleeker, smaller pager would be highly accepted by professionals. 

A sleeker, smaller, and waterproof pager, that is.

Tuesday, February 1, 2011

Yes, that computer can take a better history than you

In medical school, a significant portion of the second year is typically devoted to learning how to take patient histories.  That's because most medical students will begin patient care duties as third-years, and good patient care is dependent on getting an accurate history from the patient.

Learning how to structure the interview, respond to your patient's emotions, and elicit all of the needed clinical information is a daunting task.  I remember feeling so lost and confused in my first few sessions; the attendings made it look so effortless, yet I was struggling to remember what questions to ask.

A few years of practice later, I'm confident that I'm a better history-taker now than I was in medical school.  It came to my attention, though, that no matter how skilled I got at history-taking, something could always beat me.

The computer.

Automated patient history programs have been around for several years.  The data regarding their accuracy and acceptability is simply staggering.  No matter how comfortable patients feel with their doctor, they are much more likely to tell a computer program about their sexual indiscretion or cocaine habit than they are to tell their doc - even when they know that the doc will be reviewing what they input into the program. (1)

Automated patient history programs can screen for depression and substance abuse, and they do it with better sensitivity than an office nurse or doctor. (1) They can ensure that medication lists, family histories, and social histories are up to date.  They can even collect a 10-point Review of Systems.

Automated patient history programs aren't just for the middle and higher echelons of the socio-economic ladder, either.  They've been used successfully even in offices serving disadvantaged, low SES patients. (2,3)

Imagine greeting your patient in the room, skimming the data they've entered, asking your clarifying questions, doing your exam, and then having extra time to spend with decision-making, counseling, motivational interviewing.  Imagine, too, that your patient's HPI, ROS, family & social histories, and medication reviews have been inputted directly into your Electronic Health Record (EHR).

These scenarios are already a reality at forward-thinking family medicine offices across the country.  Dr. John Bachman and Dr. Alan Wenner have widely presented on the benefits of the automated patient history program they use called Instant Medical History (IMH).  The IMH website has some cool videos of the program in action (http://www.medicalhistory.com/).

A lot of hoopla about EHR implementation - patient portals and e-prescribing and voice recognition software - continues to permeate the pages of medical journals and newspapers.  I just can't shake the feeling that a critical element of a complete EHR system is missing from the conversation.

Let's get the patient into the EHR; let's broadcast the benefits of automated patient history software.

(1) Bachman JW.  The patient-computer interview: a neglected tool that can aid the clinician. 
Mayo Clin Proc. 2003 Jan;78(1):67-78.
(2) Pierce B.  The use of instant medical history in a rural clinic. J Ark Med Soc. 2000 May;96(12):444-7.
(3) Dugaw JE Jr et al.  Will patients use a computer to give a medical history? J Fam Pract. 2000 Oct;49(10):921-3

I have no relationship with the makers of IMH and have received no reward, financial or otherwise, for mentioning this software product.