Exceptions to the rule

Our health system recently started sending us quality measure reports - % of our patients with blood pressures under 140/90, % of our patients with coronary artery disease on cholesterol-lowering medicine, etc.  These reports include system targets for each condition, e.g., 90% of patients with hypertension with blood pressures under 140/90.  Health plans are beginning to provide bonus payments to physicians who meet these targets; eventually, some may begin penalizing those who don't.

Although some of my colleagues are unhappy with having "one more thing" to keep track of (and I can't say that I blame them), I am glad to have these numbers.  I want to know where I can improve my care.  And, I am currently working on a new quality improvement curriculum for our residents, so these statistics give me something pragmatic to incorporate into their teaching activities.

I was recently reminded, though, that while having targets and working toward them are laudable, there are a few patients who will and should not meet them.  I have a patient whose breast cancer has recently returned with a vengeance - widespread bony metastases.  She failed two courses of radiation but does not wish to pursue further curative treatment.

She also has hypertension, but I frankly don't care if her blood pressure is under 140/90.  Patients and physicians work together to control blood pressure to prevent future heart attacks, strokes, kidney failure - all problems that she is quite unlikely to live long enough to face.  This patient and I spend our appointment time talking about her goals of future cancer treatment and trying to maximize her current quality of life.  Her blood pressure of 152/94 - don't care.  (And, for the record, neither does she.)

Certainly this case should be the exception and not the rule.  One of my titles at the residency program I work for is "Director of Practice Improvement," and I truly believe that system changes are an important avenue for improving patient care.  I also would not advocate for arriving at determinations about any patient (such as "let's mostly ignore your blood pressure") without including him/her in the decision making.

But this patient reminds me that we need to leave at least a little space in our QI efforts for those exceptions who shouldn't fit the rules.  Improving this patient's blood pressure would make my personal practice report look better, but it would also be expended time and expense toward a goal neither my patient nor my best clinical judgment find important.

Yes, we should optimize care for most - but not by losing the importance of personalizing care for all.

I'm sorry

I said that phrase a lot last night during evening patient hours.

With an overfilled schedule, I mostly said it to patients who waited twenty, thirty, even forty-five minutes for me to see them.  "I'm sorry for your wait.  I appreciate your patience."  I say these sentences far more often than I should. Why is it so difficult to stay on time?

I could blame my inadequate supply of nursing staff; our health system thinks that I only need one nurse to room, vaccinate, and phlebotomize my patients.  I could blame a convoluted rooming process and the occasional lack of available rooms.  I could even blame my patients, who somehow seem to show up early or late but rarely within their allotted appointment time.

But, mostly, I have to blame myself.  "Yes, I'll freeze your warts" even though there wasn't enough time for that when we also dealt with this patient's recent Emergency Room visit.  But I know that she can barely afford her co-pay and hated to ask her to return.

And I just couldn't seem to rush telling another patient that his nagging cough and recent "bronchitis" was probably a new asthma diagnosis.  Or telling the patient after him that her wet mount didn't show yeast, as she predicted, but sheets of white blood cells - which, along with the frank cervical discharge on exam, indicated a likely STD from her new partner.

I believe that these issues deserve time, but I still don't like inconveniencing the patients who come after.  "Can I put off that bloodwork until the next visit, doc?  I can't keep the babysitter waiting much longer."  What else could I say but "of course"?

The worst "I'm sorry," though, came with the last visit of the night.  Follow-up high blood pressure with an overweight teen.  While reviewing the labs from our first visit with her and her mother, I realized that the A1C I had ordered (given her weight, family history, and the acanthosis nigricans on her neck) was not there.

Correction: the A1C I thought I had ordered.  The order was not there.  And I would have to stick her again to get it.

"I'm sorry," I said yet again.  "Remember the test I ordered to check for diabetes?  Well, it looks like I forgot to enter it into the computer.  I'm very sorry that I made that mistake.  To get that test, we'll have to draw more blood from you."

"You mean from the elbow, like before?" she asked calmly.  When I nodded "yes," she said nonchalantly, "okay."

I was so grateful for her undeserved graciousness, as I was for my earlier patients who had shrugged off my apologies for my tardiness.

Thank you, my patients.  Thanks for accepting me, mistakes and lateness and all.

Beyond Match Day

I can distinctly recall many details from my own Match Day, now eight years ago.

I remember sitting in the big auditorium at Ohio State under a restless buzz of noise.  Most students had spouses, family, and close friends with them; my parents made the trip to be with me.  They brought me a bouquet of flowers, and I still remember the crinkly cellophane creasing under my sweaty palms.

I remember walking up to the edge of the stage with my peers and being herded alphabetically.  I headed to the middle of the rows of boxes and was handed a crisp, ivory envelope with a sticker that had my name on it.  We all marched back to our seats and waited the interminable minutes for the clock to strike noon, for the announcement stating we could legally open our envelopes.

I remember sliding my finger under the envelope flap with deliberate slowness.  Everything would change after I opened it; I had been a student my whole life, but a new label was about to define the rest of my life.  Three months later, I would graduate from medical school and take my shiny new MD off to this place listed in simple typeface on that perfectly creased slip of paper.

I thought I knew what was to come.  I had worked with a lot of residents and attendings in medical school, had laughed with and wept for many patients.  In these ways, medical school had prepared me well for the demands of residency.  But nothing had prepared me for the crushing responsibility of being the one signing the orders, giving the diagnoses, consoling the bereaved left behind by my failures.

The Singing Pen has been absent for nearly two weeks now while I've been inundated by clinical work.  On the worst day during that time, I rounded on 21 inpatients with the residents before going to the office for a full schedule that included calling a mental health crisis team for a patient having a psychotic break.  I finally drifted into a restless sleep that night thinking about my application essay for residency.  I couldn't concretely conceptualize, back then, just exactly what all of that "dedication" and "hard work" was going to entail.  And yet, even in the most grueling moments, those old noble ideals still call to me; eight years later, I still love what I do.

4th years, may you all be able to say the same come March 2019.

Googling "Family Medicine" - who's defining us?

After my last post, I started to wonder about my non-family-doctor readers.  What if they are part of that large majority of people who really don't know what our specialty is all about?  Where might they go to learn more about us?

Google, of course.

So, here are the top 3 Google hits for "family medicine":

#1. Home page for the American Academy of Family Physicians.  The AAFP's home page, not necessarily inappropriately, focuses on CME (continuing medical education) for members, advocacy, and public health issues.  Some clicking around eventually leads to a "about the specialty" page, which has lots more links.  Click on one of them, scroll to the bottom of the page, and you'll find

Family medicine is the medical specialty which 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.  http://www.aafp.org/online/en/home/policy/policies/f/fammeddef.html

Hmmm.  Maybe a little obtuse...if you manage to even find it buried in the site.  Let's move on.

#2. Family Medicine Journal, the official journal of the Society of Teachers of Family Medicine;as an STFM member, I receive and read this journal regularly.  Much clicking around this site gives no succinct definition of family medicine.  Again, not totally unreasonable given the site's focus.

#3.  Wikipedia.  (C'mon, you knew it was coming.) 

Family physicians deliver a range of acute, chronic and preventive medical care services. In addition to diagnosing and treating illness, they also provide preventive care, including routine checkups, health-risk assessments, immunization and screening tests, and personalized counseling on maintaining a healthy lifestyle. Family physicians also manage chronic illness, often coordinating care provided by other subspecialists. Many American family physicians deliver babies and provide prenatal care.  http://en.wikipedia.org/wiki/Family_medicine 

I must admit - decently done, Wikipedia. 

The Google hits further down start focusing on "find a local family medicine doctor" and family medicine residency programs.  So, truly, those people seeking to find a succinct answer about what our specialty is will probably stop with that Wikipedia link. 

National Family Medicine organizations, as a member of all of you, I implore you to add some simple definition of Family Medicine to your home pages.  I get that promoting Family Medicine to the lay public isn't your main agenda for these sites designed for physicians.  (Though maybe it should be on the agenda somewhere.)  But these sites are at the top of the Google "hit list" for our specialty, which confers responsibility on you.  Don't make people dig through your sites to find out who we are, and don't leave the job of defining us to unsanctioned voices on Wikipedia.

We, as a specialty, must speak with a bolder and clearer voice.

Another commercial touting "specialist" ("partialist"?) care

A rather disappointing commercial is making the rounds on the local radio stations here.

In the commercial, the voice of a mother is heard talking about how scary it was to take her young son to the Emergency Department with his first asthma attack.  A deep, male voice follows, intoning that "even a single trip to the Emergency Department with a breathing problem" indicates the need for this child (and, by association, your child) to be seen by the "asthma specialists" at our local children's hospital.  The commercial ends by reassuring parents that these specialists "will work with your child's pediatrician" regarding the treatment plan.

The family docs reading this post doubtless already know where I am headed.

1. A single trip to the ED with asthma does not necessarily indicate the need for consultant* management.  Perhaps the family is having trouble affording this child's asthma medication.  Perhaps the office didn't make room to squeeze this child into the schedule.  Perhaps there's a trigger - dust, cockroaches, pollen, even a pet -that's setting this child's symptoms off.  Regardless, the implication that one event should trigger automatic consultation, without discussion between the family and the child's primary doctor, is ludicrous.  Family doctors and pediatricians both receive more than adequate training to treat most kids with asthma, and the care they provide is often more cost-effective.  Knee-jerk consulting irresponsibly drives up cost and fragments the provision of patients' care.

2. Referring to the child's primary doctor as a "pediatrician" is a subtle tactic designed to imply that all children need a pediatrician and, by inference, further implies that family doctors are incapable of providing quality primary care to children.  This kind-of language is divisive and unnecessary.  The world needs us both.  A more inclusive phrase such as "your child's doctor" would have been just as easy to use.

These assumptions reflect the need for Family Medicine to more aggressively market itself.  Many people know what "dermatologists" and "cardiologists" and "pediatricians" are - not exactly simple, self-explanatory words.  Yet these specialities have successfully branded themselves and their services to the lay public.  Given all that we offer, "Family Medicine" should be an easy sell - but the vast majority of Americans do not know what our specialty is and does.

It is time for all of us family docs to proudly share who and what we are.

*  I prefer the term "consultant" to "specialist" - after all, since I'm board certified in the specialty of Family Medicine, I'm a "specialist," too.  (Those more radical family docs pushing for the word "partialist" to describe those physicians only focusing on one part of the body - I'm with you.)