Monday, December 19, 2011

Mechanics truly are doctors for cars

Last week, my car got a flat tire.  I rolled into the local dealership the next day to replace my donut spare with a new tire (along with a new tire for the opposite side, of course).

I had only that one issue on my agenda initially, but as I drove to the dealership, the little sticker in the corner of my windshield reminded me that I was overdue for an oil change.  Oh, and that non-urgent factory recall on the transmission needed attention.  It seemed like a lot to take care of, and I figured I'd probably need a return visit to get all of those issues addressed.

I was a little apprehensive about what they'd be like.  I don't speak "car" very well, you see.  I often have trouble understanding the explanations I get from mechanics, and they often don't understand what I'm referencing when I mention problems in lay car language like "a funny rattling noise."  Much like a physician, they have to ask "when does it happen?"  "how often?"  "what seems to bring it on?" to decipher my car's symptoms and obtain the information they need to diagnose and treat.  I tend to ask a lot of questions, and they tend to need to ask a lot back, which doesn't always go over well in busy carshops.

So, I was pleasantly surprised to discover that this dealership service center was my kind-of place.  Their routine check turned up some filters way overdue for a change (I confess to not being very good at remembering such routine maintenance needs), and their computer system alerted them to the transmission part recall before I could even ask about it.  They offered me a loaner car so that they could take care of the recall - and the filters, and the oil change, and the new tires - in a manner convenient to me and my needs.

And, happily, they explained everything that was going on in plain English. Patiently.  Like they had all the time in the world for me, even when it was clearly very busy there.

I would like to be that kind of doctor working in that kind of practice.  I'd like my patients to rely on my electronic record to prompt us when certain routine health maintenance needs are due.  I'd like for our office to make taking care of their healthcare needs as convenient for them as possible.  I'd like for them to trust that I will understand their non-medical story and share my thoughts back with them in plain English, while giving them my full, non-rushed attention.

The analogy only goes so far (I'll defer comment on car commercials, stereotypical car sales people, etc...), but I was fascinated by the many similarities between that car service center and a medical office.

We could learn a lot from them.

Tuesday, December 13, 2011

My BHAG for Family Medicine

I have a BHAG (Big Hairy Audacious Goal).

I want people to hear "Family Medicine" and know that it refers to a medical specialty dedicated to providing relationship-based, patient-centered health care.

I want people to know that family docs take care of a lot of complicated, challenging diseases - and not usually in isolation.  Our patients have high blood pressure, complications from type 2 diabetes, congestive heart failure, depression, chronic kidney disease, emphysema, anxiety, asthma, and coronary artery disease, to name a few; treating each of those conditions individually is nothing like treating them in relation to each other.

I want people to know that I trained for three years to become an expert in my specialty.  During my Family Medicine residency, I learned about providing preventive care.  I learned how to treat a multitude of acute problems - colds, fractures, lacerations, rashes, etc.  I learned how to deliver babies, resuscitate victims of cardiac arrest, and drop a central line into a coding patient.  I can take off your moles, skin tags, and warts.  I can remove your ingrown toenail and treat your acne.  I can obtain your pap smear, discuss your birth control options, and treat your STDs.

I want people to know that I can care for your kid and your grandparent.  I routinely counsel teens about sex, drugs, and rock 'n' roll.  I am comfortable in offices, hospitals, maternity wards, newborn nurseries, intensive care units, nursing homes, and even patients' homes.

I want people to know that Family Medicine residents learn about using the best medical evidence and the latest medical technology to guide decision-making conversations with patients. They can intelligently sift through the tremendous reams of medical studies that are published daily to pull out the information most relevant to their patients.

I want people to know that those residents learn how to work within a healthcare team.  Nurses, medical assistants, pharmacists, care managers, social workers, administrative staff - it takes all of us to provide outstanding care.  These incredibly important people are my hands, eyes, and ears into the thousands of little tasks that must get done every day in the office and at the hospital.

I want people to know that no medical specialty is as devoted to medical education as Family Medicine.  The Society of Teachers of Family Medicine holds an annual meeting devoted solely to medical student education.  We are one of only a handful of medical specialties with an entire fellowship (post-residency training) devoted to faculty development - training the next generation of academic Family Medicine teachers, researchers, and leaders.

Lastly, I want people to know that family docs do everything that they do in the context of our patients' belief systems, families, and communities.  Our specialty is the only one that mandates dozens of hours of educational time during residency about the doctor-patient relationship.  How to help folks quit smoking/over-eating/whatever, how to tell someone that the biopsy did show cancer, how to mediate family disagreements about end-of-life wishes - this behavioral instruction is just as important to a Family Medicine resident as the pathophysiology, treatment, and prevention of disease.*

If you're not a family doc, I bet you didn't know all of those things.  And the blame for that truth lies squarely with us as family docs.  Frankly, other specialties have been better than us at promoting themselves.  You all likely know what a dermatologist or a cardiologist is, even if you're not working in the medical field. Family docs can learn a lot from how other specialties have advanced the interests of their patients by advancing their specialty's cause; it's something we have failed to recognize the importance of until now.

Because of that failure, Family Medicine is not understood - and thus not valued - by the public, by politicians, by health plan administrators, and by too many of the other people who make decisions about health care in this country.

We need to show them what Family Medicine is all about.

My BHAG is to share Family Medicine with the people who don't know about us yet. I hope that this blog does that in some small way; certainly, many of the Family Medicine bloggers and tweeters out there are doing it in a bigger way.

But, I don't think that's enough.  We need more.  We need an #FMRevolution.  I have to believe that there's something even bigger, hairier, and more audacious that we could do.  I wish that I knew just what that that big, hairy, audacious thing was. Fortunately, though, I am but one of many.

It will take all of us to get the chorus of Family Medicine to echo across our nation.

* Am I saying that other specialties don't care about relationships with patients, or patient-centered care, or evidence-based medicine?  Absolutely not.  But the statements above are true: other specialties do not systematically devote protected time in residency training about these issues the way Family Med residencies do.  You could argue that other specialties don't need this training as much as family docs, do, I suppose.  But that's for a future post...this post is about trying to boldly define our identity as a specialty.  Lambasting other specialties is not on my agenda.  Advancing the cause of Family Medicine is.

Tuesday, December 6, 2011

The noncompliant patient (that was me)

I alluded to an incident in my prior post that I'd like to share more about.

For you non-docs, "curbsiding" is stopping a doc (usually of a different specialty than you) that you run into to ask their opinion about a patient case.  They don't get paid for that, of course, but it's usually a common courtesy among physician colleagues.

So, in this scene I tried to curbside one of my pulmonologist teachers and colleagues about "my patient's" (really mine) frustratingly worsening coughing fits.

The scene: busy hospital hallway.
The players: Dr. Jen (of course) and Dr. K, prominent pulmonologist well-known to myself and the rest of our community hospital.

Dr. Jen:  "Dr. K, can I run a patient by you?"
Dr. K:     "Sure."
Dr. Jen:   "Well, see, I have this 30-year-patient who's been having recurrent bronchitis symptoms - mostly bronchospastic coughing - with some persistently decreased peak flows.  I've got her on albuterol and actually bumped her from Flovent to Advair to control her constant coughing.*  I hate to label her as asthma for the first time so late in life, especially without any wheezing, but..."
Dr. K:    (narrowing his eyes) "Is this you?"
Dr. Jen:   *gulp*  "Um, well, ah....yes."
Dr. K:     "Jen, you have asthma."
Dr. Jen:   "No, you're supposed to say, 'Jen, stop being such a typical resident hypochondriac.'"
Dr. K:     "Make an appointment with me, okay?"

I did.

I was not a compliant patient in the beginning; I hated the idea of having a chronic disease, of being "sick."  I evolved from "healthy" to juggling a twice daily inhaler for my lungs, two inhalers for my nose (uncontrolled allergy symptoms worsen asthma, and I've got allergic rhinitis like crazy), a pill for my allergies, and a pill for my asthma.  When Dr. K picked up on my frequent heartburn, he added a twice daily pill for that.*  "Hate" is too gentle of a word for the emotion I felt when I looked at all of those pill bottles and inhalers.

Dr. K was the rare physician's physician.  Through 5 years of treating me, he saw straight through my unimaginative excuses and attempts at self-deprecation.  He picked up on subtle clues in my history and exam - clues that I hadn't even put together myself - that necessitated further evaluation and action.  He gently prodded me to realize that, despite my feeble attempt to convince myself otherwise, I really did need all of that stuff.

I started taking all of my meds as prescribed, and, lo and behold, started to feel like myself again.  I could exercise without getting faint, and I wasn't coughing all over my patients and colleagues.  Do I still hate carrying my albuterol inhaler and spacer with me everywhere I go?  You betcha.  But I have come to accept that I have a chronic disease, and it's not going away.  Dr. K helped me to see that I'd rather kick its butt by taking good care of myself than live in denial and feel miserable.

I tried to thank him before I moved, but he deflected my attempt with kind words about enjoying our time working together.  I like to think that he knew how much he had helped me but was being humble; sometimes, though, I worry that he just was so effortlessly skilled that he didn't recognize just how powerfully he impacted me.

I can only aspire to be as much.

I know; the asthma-reflux connection is controversial.  But try telling that to a pulmonologist.  (And, at least I'm not having heartburn all day any more.)
** In those days, we had lots of samples in our office cabinet.  Since then, most academic institutions refuse samples from Big Pharma, given the evidence that they affect our prescribing habits even when we're aware that they can: (  Looking back, I have to wonder if having those samples available postponed my treatment seeking.

Thursday, December 1, 2011

Doctors need doctors, too

A couple of days ago, I was sitting in a family doctor's office as a patient, waiting to meet my new PCP.

We physicians are notorious for neglecting our own health; a reported 30-50 % of physicians don't even have a PCP.*  I have certainly been guilty of self-treating my own issues, which were sometimes probably reasonable (gluing my small finger laceration instead of going to the ER for a stitch) and were sometimes probably not (self-treating my asthma during residency).

After my friend and colleague suicided,** though, I began reading a lot about physician health, both mental and physical.  I finally approached a pulmonology colleague about my worsening asthma symptoms and got myself to a PCP for some admittedly overdue health maintenance.  Ever since, I have been haranguing the residents I work with about their own health, urging each to have a PCP to call his/her own.

So, there I was, following my own advice, waiting to meet my new PCP in this new town.  And, I was nervous.  Very nervous, truth be told.  Would he be nice?  Competent?  Somewhat close to on time? Weirded out that I'm a family doc, too?  Family docs can be fairly harsh critics of other family docs when they're the patient, after all.

As I sat there, I began thinking about all of the new patients I've seen since arriving here.  Maybe they sat in our waiting room wondering about me with similar apprehensions.  Did I allay their fears?  Most of them have been quite gracious and welcoming to their newcomer family doc.  I resolve to be less family-doc-critic and more gracious-patient when I meet my new doc.

He turned out to be quite kind, highly competent, and very respectful.  And, yes, I behaved myself, thank you very much.  :)  I walked out of his office pleased with the encounter and satisfied that my health is in good hands in this new city.

I hope I've succeeded in allaying my new patients' fears as well.
** see post date 11-15-11