Weekends & Holidays

Ever since medical school, I've found rounding in the hospital during the weekend and/or holidays frustrating.

You'd think that hospitals would be 24-7 kind-of places, right?  I'll grant that patients certainly stay in the hospital during weekends and holidays.  Nurses and doctors attend to them, meals still come, rooms are still cleaned.  However, many of the important people who work in the hospital don't work during the weekend or a holiday unless there's an emergency.

Let's say that you're a patient admitted with chest pain.  Your initial testing was okay - you're not having a heart attack right this second - but the docs want to make sure that you're not the verge of having one.  Your medical team decides you need a cardiac stress test.

Hope you didn't come in on a Saturday night, though, because your hospital doesn't do stress tests on Sundays.  You'll spend an extra night in the hospital waiting for that stress test (or echocardiogram or non-urgent cardiac catherization) Monday morning.

Lest the cardiology department feel singled out, here are other common hospital procedures that are rarely done on the weekend, especially Sundays (with the exception of life-threatening conditions, where someone must come in from home to perform the test/procedure):
               MRIs, CT scans, ultrasounds
               Colonoscopies/EGDs/ERCPs
               Most non-urgent surgeries
               Social work assistance with transfer to rehab facility or nursing home
               Financial aid officers to set up discharge care plans for uninsured patients

I understand that all of these procedures require people who are less well paid than docs to come in and assist or perform them.  I also understand that work-life balance is important for health care workers.

Staying an extra 24 hours in the hospital, however, is not a low-stakes proposition for patients.  It's expensive, for one thing.  An average night in a US hospital runs from $3000 to $4500, depending on who you ask.(1)  And, although many are working to eliminate medical errors, hospitals still remain rather unsafe places to stay unnecessarily. Preventable medical harm kills upward of 100,000 people a year in the US. (2)

Some hospital workers who must be there 24-7 include the nursing staff.  They manage to create schedules that fairly divvy up weekends and holidays, exchanging time off during the week.  Creating schedules for hospital workers that maintain a constant presence - regardless of weekends or holidays - has been a way of life for nurses for years.  It's high time that the rest of us followed their example.

Until every service that's available on a Monday is available on a Sunday, though, our patients will see that having our weekends and holidays off are worth more to us than providing them with safe, cost-effective care.

(1) http://meps.ahrq.gov/mepsweb/data_files/publications/st164/stat164.pdf, http://healthpopuli.com/2010/11/23/luxury-goods-a-hospital-stay-in-the-u-s-a-big-mac-in-switzerland/, http://www.kaycircle.com/What-is-the-average-cost-of-a-Hospital-Stay-per-night-in-2010-Price-Range-of-staying-in-a-Hospital
(2) http://safepatientproject.org/safepatientproject.org/pdf/safepatientproject.org-ToDelayIsDeadly.pdf

Crash and burn

I teach the Evidence-Based Medicine curriculum at our residency program.  I'm passionate about this curriculum, as it teaches our residents how to be critical thinkers about the never-ending deluge of scientific data that can benefit our patients.

One of the tricky things about teaching EBM is that it involves numbers: calculating sensitivities, specificities, positive predictive values, etc.  Mixing these numbers up is not hard to do.  I create all of the materials used in this course, and I usually double and triple check my arithmetic - and then have someone else quadruple check it - before finalizing handouts and PowerPoint slides to present.

Something went terribly, terribly wrong yesterday.  The computer in the conference room was being buggy with 2010 PowerPoint, so, I opened my previously saved 97-2003 version.  As far as I could remember, it was pretty much the same.

Yeah, except that I had, in fact, actually tweaked all of the examples in between versions. The examples on the handouts that the residents had to work through. The examples on the handouts that had the wrong answers on every single PowerPoint slide.

My quadruple-checker was there, but unusually we had not been able to meet to confirm the quadruple check before-hand.  We've never had anything but a teeny tiny discrepancy before, I reassured myself.

Whoops.  Mass confusion quickly erupted as the residents started working through the problems and the wrong answers popped up on each slide.  The quadruple checker had the correct answers, thankfully, and we eventually salvaged the session by just working through the problems on a whiteboard.

I want so badly to teach that EBM doesn't have to be a scary avalanche of numbers and equations.  I want them to get the bigger picture, the concepts above the arithmetic that can enhance their patient care.  Unfortunately, today, all they got was an hour of group effort trying to puzzle through...a scary avalanche of numbers and equations.

More than teaching about EBM, though, I selfishly want my residents and colleagues to trust my knowledge and judgment.  Failing miserably in front of everyone exposed my imperfections, making me uncomfortably vulnerable.

I wish I was a perfect teacher and a perfect doctor, and being reminded that I'm far from perfect is hard to stomach.  Maybe, though, my public failure will make the people I work with a little less afraid to be imperfect around me.  Maybe this unpalatable dose of disgrace will break down any barriers I or others have about labels such as "teacher" and allow more genuine, unfettered working relationships.  That would almost make yesterday's debacle worth all of the humiliation.

Almost.

"Beauty" - at what price?

Wrinkles are bad.

So are small breasts.

Also crow's feet and age spots.

Jiggly arms and muffin tops.

Don't forget untrimmed pubic hair.

This tirade isn't limited to women.

Guys, are your muscles ripped?

Chest gleamingly hair-free?

Male member sufficiently enhanced?

On a regular basis, I see 9 to 11 year-old girls who tell me that they're cutting back on what they eat because they're "fat."  While I'm examining them, they will point to the normal pubertal fat deposit just below the belly button and bemoan this unwelcome detraction from a perfectly flat abdomen.  Although some of these girls are overweight, most are not.  What have we done, as a society, when preteen girls are this unhappy with their bodies?

Why are we allowing advertisers and mass media to define beauty? Since when did aging become a condition or disease to be treated?  How did 18-year-old Barbie doll figures become the standard of beauty?  Mass media and the beauty industry - admittedly only pandering to what consumers respond to - have picked up on our insecurities.  We are assaulted on a daily basis by advertisers' impossibly airbrushed and retouched models selling everything from stilettos to vitamins.*  These companies succeed at convincing us of our "flaws" that their products can "fix."

As physicians, we must beware of being caught up in this over-emphasis on appearance. We contribute Botox for wrinkles, silicone for sagging breasts, and the diet pills to lose 10 pounds.  In so doing, though, are we contributing to the problem?

Beauty treatments and the desire to look attractive are not, in and of themselves, fundamentally bad, and neither are the health care providers who assist with them.  The danger lies in allowing our focus on those treatments' goals to pervade our internal sense of self-worth.  As physicians, we have a sacred trust with our patients; we treat each person, regardless of appearance, with dignity and respect.  We must be cautious against contributing to the fallacy of perfect appearance with our skills and prescription pads.

Our intrinsic value as human beings has nothing to do with our skin and breasts and muscles.  Each of us can help to push back against these social pressures by teaching that the altered pictures of people in magazines make us long for what is unattainable.  We can compliment each other as often on our internal qualities as we do on new hairstyles or clothing.  My patients' resilience, patience, and thoughtfulness, often in the face of great struggles, are what is truly beautiful about them.

Let's shift the conversation toward that definition of beauty.

* A new movement is committed to exposing the excesses of retouching in the beauty industry: http://jezebel.com/5115667/2008-photoshop-hall-of-shame, http://www.sfgate.com/opinion/article/Jamie-Lee-Curtis-has-nothing-to-hide-2805025.php#photo-2210632, http://www.diet-blog.com/06/celebrity_retouching_10_reasons_to_revise_your_reality.php.

Perfume and office visits don't mix

That perfume that you heavily doused yourself in this morning may be your signature scent.  It may help you to feel more feminine.  It may be an important part of your overall persona.  When not in tight spaces with others, feel free to douse away.  As your doctor, though, I must ask that you refrain from wearing it (or at least as much of it) to office visits.

Along with about 8.4% of the US population (1), I have asthma. To promote good doctor-patient communication, I can't sit too far away from you.  To perform a high-quality physical examination, I must enter into your personal space.  Several minutes of inhaling that strong scent, however, can cause me to have trouble breathing.

I've never been brave enough to bring this up before, fearful of irrevocably harming our relationship.  You have the right to wear as much perfume as you like.  It's not your fault that I have asthma, and it's not your responsibility to help me deal with it. But the boundary between your rights and my responsibilities seems to be tilting more toward me.  I'm also compelled to speak up for the 1 in 12 people around you with asthma.  A quick Google search confirms that this is a common issue for us asthmatics. (2)

I despise these hypersensitivities that humiliate me with coughing fits after exposure to what should be innocuous stimuli; in a more perfect world, I could at least conceal my problem from those around me.  Maybe part of my reticence to broach this issue relates to an intense desire to present myself as "normal and healthy" to those around me, including my patients.

At the end of the day, too, I value the doctor-patient relationship too highly to jeopardize it for something as banal as perfume.  After all, docs sacrifice other elements of well-being to do their job.  Most of us buy into the premise that a career in medicine requires dedication and sacrifice.  So, for now, I will settle for this generic cyberspace plea:

On behalf of the 25.7 million Americans with asthma, please think twice about how much of that perfume you apply before heading out the door.

1 http://www.cdc.gov/nchs/data/databriefs/db94.htm
2 http://www.everydayhealth.com/specialists/allergies-asthma/feldwig/qa/painful-perfume/index.aspx, http://asthmamomlife.blogspot.com/2011/11/perfume-as-asthma-trigger.html, http://forums.webmd.com/3/asthma-exchange/forum/1875, http://whatallergy.com/2012-02/please-dont-wear-perfume

Recipe for a vital primary care workforce

Thanksgiving is just around the corner, and so it seems appropriate to share a recipe:

Recipe for a vital primary care workforce
1. Accept more students into medical schools who are likely to choose primary care.
2. Validate medical students' interest in primary care.
3. Provide adequate Family Medicine and General Internal Medicine training opportunities.
4. Enact meaningful payment reform.

Now, a sub-par cook such as myself needs a little more detail than just the basics to pull off such a complicated recipe...

1. Accept more students into medical schools who are likely to choose primary care.
Studies show that medical students who choose primary care are more likely to:
    Live in a rural area and/or plan to return to work in a rural area (1)
    Live in a disadvantaged area and/or plan to work in a disadvantaged area (2)
    Have grown up in a low or middle socioeconomic neighborhood (1,2)
    Not plan a research career* (1)
    Believe primary care is important and plan to practice primary care (1,4)
    Be indifferent about earning a high income after residency (1)
    Be female, older, and/or married (3)

2. Validate medical students' interest in primary care.
It's not enough to accept the right students into medical school; schools must also support interest in primary care.  Here's what's been proven to increase the number of grads choosing primary care careers:
    Increase mandatory rotation time in Family Medicine and General Internal Medicine. (2)
    Rotate at two or more Family Medicine sites. (4)
    Require a longitudinal primary care experience.  (3)
    Expose students regularly to academically credible FM/GIM faculty. (3)

3. Provide adequate FM and GIM training opportunities.
Medical school graduate numbers are increasing as new schools open and existing schools expand their class size, but there are not enough residency slots for all of them. Some estimate that we will need 52,000 new primary care doctors by 2025, largely thanks to the Affordable Care Act, (6) and our capacity to train them is lacking.  Additionally, few Internal Medicine residency graduates are practicing primary care these days, so the bulk of those 52,000 will likely need to be Family Medicine docs.  Unfortunately, Family Medicine residencies are not growing in numbers and capacity but are instead closing at an alarming rate. (5)

One of the local health systems here closed a Family Medicine residency program to "rebalance" their budget and workforce needs.  Those GME slots are going to a vascular surgery residency.  Local pressures are leading health systems to make short-sighted choices about what kind of medical specialities we are training our future physician workforce for.

4. Enact meaningful payment reform.
Payors devalue primary care by paying more for procedures and specialist care than for comprehensive, preventive primary care.  Case in point - our residency program practice earns about twice as much for doing a circumcision (a simple procedure that takes about 10 minutes) than for admitting a patient with complicated problems to the hospital.  We earn more for snipping off a skin tag than providing 45 minutes of direct patient counseling about chronic disease.  

The current "Medicare physician payment formula...rewards volume over quality and that discourages growth of primary care." (7)  Systems produce what they are designed to produce, and right now our payment system disincentivizes primary care by better rewarding procedures and specialists. Unnecessarily expensive care does not produce better patient outcomes, and it certainly won't help the US balance its bloated budget. (8)

Shifting our nation's health emphasis back to quality primary care will take deliberate effort by many parties.  I would argue, however, that the payoff will be more than worth it.  US counties with more primary care docs have lower health costs and longer life expectancies compared to counties with a heavier emphasis on specialists. (9) Yes, we need our specialist colleagues.  

But I'd argue, at this point in US history, that we need Family Medicine more.

1 http://www.ncbi.nlm.nih.gov/pubmed/1985676
2 http://www.ncbi.nlm.nih.gov/pubmed/14963077
*  Not to say that research in primary care isn't vitally important...just citing the studies.
3 http://www.ncbi.nlm.nih.gov/pubmed/7612128
4 http://www.ncbi.nlm.nih.gov/pubmed/15057616
5 http://www.ncbi.nlm.nih.gov/pubmed/14603401, http://www.ncbi.nlm.nih.gov/pubmed/1544533
6 http://www.thefiscaltimes.com/Articles/2012/11/19/Wanted-52000-More-Primary-Doctors-by-2025.aspx#page1
7 http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20121107electionresults.html, http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentiethreport.pdf
8 http://www.jsonline.com/business/looming-primary-care-shortage-starts-with-med-school-to39lu9-134971463.html
9 http://bostonreview.net/BR30.6/starfield.php

Medicine needs to join the 21st century

Last week, I wanted to start a new medication for my patient.  Her insurance company didn't want to cover it.  So, I called her insurance company to argue my side.

After listening to some awesome (not) hold music, I got to speak with an automated system that asked for information about me and my patient.  Okay, this was kind-of impersonal, but it wasn't particularly offensive to me.  Then more awesome (not) hold music to speak with a "representative."

The representative introduced himself by his first name.  Perhaps he was having an off day, but his customer service skills were a bit lacking.  He also appeared to have very little medical knowledge; he read through a list of conditions that this particular medication is approved for, mangling most of the pronunciations.  After answering "no" to this list of 20+ conditions (and assisting him with pronouncing most of them), I was put on hold again.  Yep, more awesome (not) hold music before being informed that the pharmacist declined my request. Next step: wait on hold again to finally speak with a physician in peer-to-peer review.

I want to be responsible with costs for my patients and the health care system. I'm sure at times I am wrong, and a more affordable alternative with equal efficacy exists.  It's not that I'm unwilling to hear that - I would just desperately prefer a more efficient way. I didn't need an insurance company representative to tell me that my request wouldn't meet their usual criteria, but I had to be officially "denied" before I could speak with a doc who could override it.  Why must policing medication costs involve sucking time away from busy primary care docs who don't have that time to spare?

Although I am unhappy with this particular episode, my goal is not to vilify insurance companies; they also have a job to do, and many of my patients benefit from their services.  Let's face facts; physicians are our own worst enemy when it comes to the outrageous spending on health care in the U.S.*  As physicians, we need to stop blaming the insurance companies for the need for these reviews and take responsibility for the costs of what we prescribe.  We need to encourage better interfaces among all players in the health care area.  Our patients need us to work collaboratively with insurers to make their care better.

Insurers' scrutiny of our prescribing is not likely to go away any time soon, though, yet the problem with these medication reviews is not the company representatives or the awful hold music; it's the phone process itself.  It's the 21st century, yet we're using the telephone like it's 1950.  Maybe that nifty 20th century invention, the computer, could do better...

How about an automated cost-rating system for physicians within insurance companies? Maybe if you're a "red flag" doc who frequently prescribes unnecessarily expensive drugs and treatments, then you have to be go through peer review more often and maybe even do some extra CME on cost containment.  If your track record shows mostly low cost interventions, though, then perhaps you get a free pass or two.

How about an online review process?  Insurance companies could be super-transparent about the covered conditions, and if your request didn't fit, docs could immediately send a HIPAA-secure message to peer review.

Health care reform must include simplifying the processes that waste resources; and, yes, physician time is a valuable resource.  This frustrating, inefficient process of getting medications approved is among many others contributing to our skyrocketing costs, aggravating insurers and docs, and discouraging students from a career in Family Medicine.  We will need more family docs in future years, not less. And, we will need them actually practicing Family Medicine instead of listening to awesome (not) hold music on the telephone.  

Surely, together, we can find a better way.

* http://www.ihi.org/offerings/Initiatives/IMPACTingCostQuality/Pages/Background.aspx
CME = Continuing Medical Education.  Most medical specialties require so many hours of CME every year to maintain your board certification.
HIPAA = Health Information Portability and Accountability Act: http://www.hhs.gov/ocr/privacy/

Burnout & redemption

I didn't consciously decide to put my blog on hiatus these last few months.  I just got too busy one week to post, and then the next week, and then the next...

I admit to getting overwhelmed with some professional and personal challenges during this time.  Part of my unintentional blog hiatus was certainly related to those issues; they were the only things I could think about, yet I didn't want to share them on this blog.  The only problem was that those challenging situations were what I needed to write about.

The professional stuff, well, just isn't appropriate to share in a public space.  And, as for the personal stuff, I wish that I had the courage to share the details of my life with you all, but I don't.  I love reading the medical bloggers who are bold enough to let us peer into their lives, and  I'm grateful for their courage.  Through their stories, we gain a deeper appreciation of our humanity.  Blogging about the specifics of my personal issues, however, is just not for me.  I'll reassure you that my health and marriage are fine, and that will have to sate whatever curiosity you might have.  :)

As I look back on those four months, though, I recognize that more was going on than just challenging situations.  I became emotionally overloaded.  The trivial annoyances of my job became herculean, and I struggled to find the joy in being a doctor.  It took more and more emotional energy every day to rally up a positive facade with my patient care and teaching.  I felt like I was stuck in an impossibly deep rut.  I was burnt out. Would I ever love my job again?

These feelings are fairly prevalent among physicians.(1)  Primary care docs, especially, report higher levels of burnout than our specialist colleagues.(2)   So, what's a burnt out doc to do?

Well, from the JAMA article below: (1)

Strategies to Prevent Physician Burnout 

Personal

Influence happiness through personal values and choices
Spending time with family and friends
Religious or spiritual activity
Self-care (nutrition, exercise)
Adopting a healthy philosophical outlook
A supportive spouse or partner 

Work 

Control over environment: workload
Finding meaning in work and setting limits
Having a mentor
Having adequate administrative support systems

Easy, right? *insert sarcasm here*  These goals are great thinking about long term and the big picture, but what about for when you're stuck in that rut?  How do you clamber out?

I can only speak for myself, but I was pulled out of my rut this past weekend at the Family Medicine Education Consortium annual conference.  700+ family docs - and future family docs! - provided a whole lot of positive energy around our collective efforts to improve health for our patients and communities. They reminded me about why I felt called to this profession in the first place: I get to combine my science geek-ness with my drive to contribute to making the lives of those around me better.  I get to interact with amazing people who inspire me push the envelope even farther.  I get the joy of being a "friend with special knowledge" (3) to my patients, and I get to contribute to future family physicians' educations, ensuring that they will deliver quality health care to the generations to come.

For the long term, those strategies above are worth championing, but for the short term, try some time away from the office with your tribe.

Good-bye, rut.  I'm back.

(1) http://jama.jamanetwork.com/article.aspx?articleid=195312
(2) http://www.eric.vcu.edu/home/resources/pipc/Other/Clinical_Skills/Article_Physician_Burnout.pdf                     
(3) The kind of doctor John Steinbeck wanted: http://www.lettersofnote.com/2012/09/what-do-i-want-in-doctor.html

What biases lie behind your narcotic prescribing?

Narcotic pain medication prescribing is an issue heavily laden with emotion these days.  I have observed that most doctors tend to fall on one side of a spectrum bordered by these two extremes:

"Undertreated pain is worse than addiction."

On one end is the doctor who is deeply, morally troubled by patients in pain.  This doctor is not unaware of the risk of addiction but is willing to risk being taken advantage of by a wily narcotic seeker rather than leave pain untreated.  This doctor knows that undertreated pain can tremendously decrease his/her patients' quality of life. He/she feels that relieving suffering is one of the most important responsibilities of a physician.

"Addiction is worse than undertreated pain."

On the other end is the doctor who is deeply, morally troubled by the possibility that he/she may contribute to someone's narcotic addiction.  This doctor is not indifferent to pain but is willing to risk undertreating pain rather than inadvertently create an addict.  This doctor knows that every single narcotic addict gets their ongoing pill supply, directly or indirectly, from a physician's prescription pad. He/she feels that preventing the misuse of these dangerous medications is one of the most important responsibilities of a physician.

Most docs naturally lean toward one end of that spectrum; they are more naturally inclined to either worry about pain or worry about addiction.  I'm not trying to suggest that one way of thinking is superior to the other, as pain and addiction are, of course, both terrible problems.  

Doctors are merely imperfect human beings, and we will not always make the right decision about prescribing narcotics.  At times, we will not treat pain that we probably should, and, at times, we will prescribe narcotics for someone we probably shouldn't.  Which end of the spectrum we fall on might just determine which of those two outcomes is more likely for our own patients.

I lean more toward the "pain is bad" end, myself.  I hate to see people in pain, but, like most family docs, I've also been burned a few times by clever narcotic seekers. I have to constantly remind myself to remain vigilant in my efforts to detect narcotic abuse, as my natural inclination is to trust people until they've proven themselves untrustworthy.

I've shared these observations with the residents I work with, and they can usually describe which side of the spectrum they each prefer.  This self-awareness is important for us as docs; by recognizing our biases, we can consciously decide how much we will allow them to influence our decisions.

Better defining the values behind physician behavior may be a necessary step to improving care for both untreated pain and narcotic addiction.

Writing Meaningful Evaluations

In medicine, especially in academic medicine, you write a lot of evaluations.

You evaluate each resident after each rotation you've worked with them on.
You evaluate each resident procedure you've supervised, each delivery, each injection.
Each medical student that rotates through.
Educational presentations and lectures - yep.
Summative evals for your resident advisees twice a year - check.
CME conferences, hospital conferences, online CME.

Sometimes these evaluations are of high quality and are useful to the student/ resident/presenter.  Sometimes they're not, and the student/resident/presenter misses out on the opportunity to make improvements and solidify what's working well.

So, here's The Singing Pen's Guide to Writing a Meaningful Evaluation:

1. You should have spent adequate time with the evaluatee* to write a fair and balanced evaluation.  If not, decline the eval.

2. Yes, circling the numbers and filling in the checkboxes is important.  But of equal importance are the comments that you write.  For medical students, the positive comments may end up in the student's Dean's letter; for residents, in letters of recommendation for future jobs.

3. Speaking of those circles and boxes - find out what the grading institution's definition of "average" or "competent" is...and resist the urge to grade inflate.  (Grade inflation is rampant in American medical schools.**)  One rule of thumb is that only the top 5-10% of your evaluatees should be given  "exceptional" or "honors" grades.

4. Not sure where to start with your comments?  Focus on the circle/checkbox attributes that you ranked either lower or higher than "average."  Provide specifics about why you felt the evaluatee was above or below what is expected.

5. If your evaluatee is deficient in some way, say so. (Medical schools, residencies, etc should be thoughtful about keeping this information confidential.)  This axiom should go without saying, but most medical evaluators do not like to give corrective or negative feedback.** Medical students should not arrive at residency, for example, with deficiencies that should have been addressed in medical school.

6. When you need to give corrective feedback, make sure it is objective (about observed behaviors or skills).  Again, sharing your specific observations is very helpful.

7. Balance your corrective feedback with positives that you observed.  An evaluatee early in his/her medical career may lack knowledge and experience but may still demonstrate compassion, eagerness, and team spirit, all of which deserve recognition.

8. If possible, give informal feedback in the middle of the rotation/year/etc to your evaluatee.  This gives the evaluatee the opportunity to improve shortcomings while building confidence regarding what he/she is doing well.  (If your evaluatee improves - or doesn't - that is also valuable info for your final eval.)  #5 issues should never be a surprise to evaluatees when the final evaluation arrives.

Remember, high quality evaluations provide specific feedback about behaviors or skills that the evaluatees are either doing well or should improve.  If it's the latter, provide specific advice regarding the steps needed to improve that skill.

*And, no, "evaluatee" is not a real word.  But it should be!

** http://www.stfm.org/fmhub/fm2008/may/paul333.pdf

FM, IM, peds & the state of primary care in the US

In general, most people don't understand what Family Medicine is, maybe because family docs tend not to share who they are and what they do as much as other specialists.  For example, have you seen the ads touting the importance of having a skin exam by a dermatologist?  Yet there has been no such widely recognized campaign by Family Medicine.

Yet family docs toil on, unaware that our failure to share the value of our specialty, and of primary care in general, is leaving a sizable gap in the conversation happening around health care reform in the U.S.  I am frequently asked by patients "what exactly is family medicine?" and "aren't you the same as an internist?"

So, the Singing Pen presents the lay person's guide to primary care specialties:
(For a general overview of medical training, see my previous post on that topic.)

Family Medicine: family doctors complete a three-year residency in Family Medicine. Family doctors see themselves as physicians for the whole person across the lifespan.  We take care of newborns, octogenarians, and everyone in between.  We receive comprehensive behavioral training which comes in handy, since so many of the diseases that we deal with are related, at least in some way, to lifestyle.  The vast majority of graduates from Family Medicine residency programs will go on to practice Family Medicine, though a few will go on to fellowships for more in-depth exposure in topics such as sports medicine, obstetrics, adolescent medicine, geriatrics, and faculty development.

Internal Medicine: internists complete a three-year residency in internal medicine. Internists care for patients age 18 and older.  Most internal medicine residency programs are quite hospital-intensive; residents spend most of their time in the hospital setting rotating through the Internal Medicine subspecialties along with doing general internal medicine.  Although internists used to make up a sizable percentage of the primary care providers in the U.S., those numbers are dramatically dropping as most (80% [1]) internal medicine residency grads choose fellowships to subspecialize in fields such as cardiology, GI, endocrinology, nephrology, etc.

Pediatrics: pediatricians complete a three-year residency in Pediatrics. Pediatricians typically provide care from birth to age 18, though there are some who will see patients in their early 20s.  Pediatrics residencies are varied regarding the amount of time spent in the hospital versus in the outpatient setting, but most lean more heavily toward the inpatient end of the spectrum.  Similarly to Internal Medicine, fewer Pediatrics residency grads are choosing to practice general pediatrics, choosing instead fellowships in many of the same categories as Internal Medicine (cardiology, GI, endocrine, nephro, etc).

We need all three of these specialties in the house of medicine.  I am grateful that training programs exist to accommodate those medical school grads interested in primary care, but only at one end of the lifespan.  And, despite my frequent exhortations about the importance of Family Medicine, we need those subspecialized folks, too.

The balance is just off.  The U.S. probably needs at least 40% of its doctors to be providing primary care (2); the current percentage is a little under 30% (3, 4).  Last year, though, only about 15% of medical school grads chose a primary care specialty (4), and we already know that most of the Internal Medicine folks, and quite a few of the Peds, will choose subspecialties and not practice primary care.

Where are all of these future primary care providers going to come from?  Well, unless the proportions of internists and pediatricians choosing primary care change dramatically in the next few years, most of them will come from Family Medicine.  We need more family doctors if we're going to get that percentage up to 40%.  So, how do we bolster medical student interest in Family Medicine?

Yes, payment reform is important.  Yes, the big high-faloutin' medical schools need to stop closing their Family Medicine departments and telling their students that primary care is "a waste of your talent."

But maybe, too, the dermatologists shouldn't be the only ones with fancy ads in women's magazines.  Maybe it's time for Family Medicine to speak loudly and persistently until we are heard.  We need to supply an image of Family Medicine and primary care to our nation that reflects all that we do and how we can help the nation's health.

Primary care providers, speak loudly and with pride.  Share with your patients, your families, your politicians - anyone who will listen! - why you chose primary care. Together, we can reverse the fallacies that primary care isn't for smart people and isn't rewarding.

Together, we can change the conversation about health care.

(1) http://www.nejm.org/doi/full/10.1056/NEJMp068155
(2) http://www.aafp.org/online/en/home/publications/news/news-now/resident-student-focus/20110205cogmereport.html
(3) http://www.ahrq.gov/research/pcwork1.htm
(4) http://www.washingtonpost.com/wp-dyn/content/article/2009/06/19/AR2009061903583.html.  Also great stats in this article about the income gap between primary care and the subspecialties...in case there was any doubt about why most medical school grads don't choose primary care.

One person can make a difference - will you?

Not too long ago, I wrote about my Big, Hairy, and Audacious Goal ("BHAG") for Family Medicine.  I want every single human being in the United States to understand what Family Medicine is and why it's so valuable.  If that were so, I believe that more of the people who make decisions about health care in the U.S. would bring Family Medicine, and our health- and cost-effective care, to the head of the table.

I don't know about you, but when I hear about important and lofty goals like that, I feel like I'm too small to contribute in a meaningful way.  Sure, there's a part of me that wants to stand on the rooftops and shout "Family Medicine is a huge part of the answer!" but, then again, I'm a little on the introverted side, and I'm incredibly busy, and how would I get up on a rooftop anyway, and....

You get the idea.

I am here to tell you that there is a really, really easy way to help one piece of the Family Medicine universe.

With just 2 clicks, you can support the Family Medicine Education Consortium.

I'm currently on the board of the Family Medicine Education Consortium (FMEC), a not-for-profit corporation that incubates ideas, connects people, and catalyzes health care change in the NE region of the US.  We...

• Support programs and services that promote medical student interest in Family Medicine

• Stimulate the recruitment and development of Family Medicine faculty

• Facilitate relationships that lead to scholarly efforts relevant to Family Physicians 

• Create coalitions among those who wish to increase the number of Family Physicians in the U.S. 

(How's that for "important and lofty?")

I am so incredibly proud to be a member of the FMEC.  Yes, the AAFP and STFM are important, too.  But the FMEC has its own unique identity outside of those two organizations.  The FMEC isn't an official Academy, and it's not charged with supporting the educational efforts of an entire nation of FM faculty.  Because the FMEC does not have those responsibilities, it is free - free to be a little "crazy," as our CEO, Larry Bauer, likes to say.  

We encourage the innovation, the crazy ideas that won't all be successful, the forward-thinkers whose visions are so imaginative that no official organization, understandably, can yet sanction and support them.  And yet, without support, those ideas will wither and die, ideas that just may have the potential to change health care.  The FMEC fills that gap.  We are the home for the dreamers, and we connect the dreamers to partners who can help make their dreams come true.

When Dr. Jeffrey Brenner had the crazy idea to spend more resources on those "super-utilizer" patients (which, it turns out, really does save some serious cash in the long run), he found a willing partner in the FMEC.  The FMEC now facilitates a whole network of "super-utilizer" projects, health systems and insurance companies who are sharing best practices on reducing the health care costs - and improving the care - of the sickest, most challenging patients.

We also sponsor an annual meeting every fall where over 1000 individuals interested in FM, or affiliated with FM programs, gather to network, present curricular innovations, and share these crazy dreams.  Last year, over 300 medical students attended and witnessed Family Medicine’s vibrancy first-hand.  Supporting this meeting is a tremendous opportunity for you to give Family Medicine a step up.

Maybe you're passionate about preventing pre-term labor?  FMEC has an initiative for that.

Maybe it's ensuring high quality teaching and initiatives regarding the care of the disabled and those with special needs.  FMEC has an initiative for that.

Maybe it's improving the care of people struggling with addiction and chronic pain.  FMEC has an initiative for that.

Maybe your fire is to get more medical students to consider Family Medicine as a career.  The medical students who attend our annual conference do so for no cost except transportation, and the vast majority of them will match in FM (and, yes, many attend unsure of their specialty choice).  Maybe you'd like to help fund a student scholarship; $500 = one student's conference fee, meals, and shared hotel room.

At the risk of sounding like a bad infomercial, just a few of your $$$ can make a tremendous difference.  It's tax-deductible.  It goes directly to support the annual meeting, medical students, and the initiatives above.  (You can even earmark your funds to one of those projects if you like.)

It's a way for you to contribute in a hugely meaningful way toward those "important and lofty" goals above.  Do you have sixty seconds today to:

1. Click here,
2. Click on "Make a Contribution" in the upper left hand corner,
3. Pop in your credit card number and whatever donation you'd like.
4. Please type "SingingPen" into the "Enter description" box on the contribution screen so that we can track the folks who gave because of this blog.  (No, I don't get a kickback.  But it'd be nice to demonstrate that social media is a useful fundraising tool for us.)

No donation is too small.  If each of the people who've ever clicked on this blog site gave just $5, we could fund over 130 students to attend this year's meeting.

None of us is too small to make a difference. 

Late spring chaos

Hello, blogosphere.  Sorry I've been absent of late.  I still really like you and all - I'm just really busy these days.

I know, I know, I'm the one who volunteered to give a precepting workshop to kick start some faculty development around here.  And, yes, I'm the one who said "okay" when they asked for two nights to give all of the faculty the chance to attend.

I take full ownership for saying "yes" to giving a talk on social media to a prominent local physicians' group last week...and also for submitting a presentation to STFM that was two weeks ago.

Oh, about the evidence based medicine curriculum here...I knew I'd have to build it as I go.  It'll be easier next year.  But we still need to prepare that 50-minute teaching session that's one week from today, not to mention the talk on hyponatremia that the residents requested for the inpatient service next week.

Meeting with the statistician team tomorrow?  Check.  Need to finish draft of research proposal before then.

Somehow, every spring, things collide like this for me.  Now that I think about it, I'm not sure exactly why.  After all, this is the "down" season for most residency faculty: after the match and recruitment season, yet before graduation, new intern orientation, and the transitions of July.

I could have said "no" to most of the above.  I feel an overwhelming need, though, to build relationships here.  I've been in this job for six months, but I still feel like a lost newcomer most of the time.  I need some grounding, some familiarity.  I need to feel like people here understand my skill sets.  Otherwise, opportunities to use them may not materialize.

Blogging has had to fall by the wayside. Having lived through this cycle before, I know that the chaos of late spring will eventually evolve into the easier pace of early summer.  Orientation isn't one of my responsibilities, and July is languid heat and relative calm for me.

Please don't despair, blogosphere.  I'll be back soon.

What is "the doctor look"?

Docs who are reading, imagine this scenario.  You're walking down a hospital hallway, and someone in a white coat, stethoscope around the neck, rounds a corner in front of you and begins walking toward you.

Question #1.  You don't personally know this person, but can you tell from 50 feet away whether she or he is a doctor?

I've started randomly asking some colleagues this question, and the answer is uniformly "yes."  Doctors have no problem distinguishing other doctors from the nurse practitioners, clinical pharmacists, and physician assistants who also roam the hospital in white coats.  Heck, my questionees even volunteered that they can still tell the difference even if the person wasn't wearing a white coat (for the record, I have no interest in rehashing the Great White Coat Debate at this time).

Question #2.  "How?"  I'd ask next.  "How can you tell that person is a doctor without reading their name badge?"

The response to this question was usually a shrug of the shoulders and, "You can just tell!"

In my two-year Faculty Development Fellowship, I learned how a physician's diagnostic reasoning process develops over time.  Most expert clinicians are pattern recognition experts.  These seasoned docs, without conscious effort, match the scenario in front of them to what they have seen before.  They recognize a diagnosis without deliberately walking through a problem representation and matching it to an illness script, the way a novice physician does.

Interestingly, experts often can't explain exactly how or why they arrived at a diagnosis.  Something happens to the edges of those details we each try so hard to master in our medical training; they blur into indistinct edges, into fuzzy caricatures of diagnoses that wait for ocular input to subconsciously call them into duty.

So, I posed the above questions to my resident team this week; we were in the elevator with a gentleman with a mop and janitor's bucket wearing a hospital housekeeper's uniform.  The residents all agreed that the answer to the first question was "yes" but were stumped with the second.

The man with the mop didn't hesitate.  "It's the attitude!" he exclaimed.  "You can always tell who the doctors are by their attitude."  Unlike clinical pattern recognition, the diagnosis of "doctor" apparently does not require a career to acquire.

Perhaps, like most expert clinicians' patterns, it will defy a straightforward explanation.  He or she is a doctor because it, well, he or she just is.  No one has to explain why an apple is an apple; apples can be red or green, sweet or tart, crisp or mealy, but we recognize without difficulty that they're all apples.

Here's hoping I'm at least somewhere on the red/sweet/crisp end of that scale.

Leave it at the stage door

I've done some musical theater in the past, and anyone who's done theater knows that people who engage in the dramatic arts tend to be, well, a bit dramatic themselves.  I once had a director in college who exhorted us to "leave it at the stage door," the "it" being any of life's current issues, problems, or concerns.  He expected us to temporarily disengage from our personal dramas for a few hours to put our full energy into rehearsal.

I have thought of that phrase many times since then.  In polite, adult society, we expect each other to progress through our work days with equanimity and diligence. I can't give my learners and patients my full attention if I allow myself to be overly preoccupied with personal matters.  Sure, we might share some issues with a confidant or two, but most of the time we physicians - and other professionals, I'm sure -  set aside personal concerns during the work day.  In my observation, it's usually only when this setting aside becomes permanent neglect that this necessary process is harmful.

Sometimes, though, I can't help but wonder how many of the people I pass by in the hospital and in my office have left something significant "at the stage door."  I wonder about the cache of secrets we walk around with, issues that tear at our heart that secretly wait for acknowledgement until the workday is done.  This status quo is certainly best for our patients, but is it best for us?

Physicians are well-trained in self-neglect, in this unwritten curriculum to always put the patient first.  And, in the end, I can't bring myself to disagree with that order. This profession is about selfless service, not accolades and marquee listings.

Every now and then, though, part of me wishes we could allow ourselves to be vulnerable, too.  I suspect that we each possess enough caring to take good care of our patients and still reach out to our colleagues.

After all, that pile by the stage door probably isn't getting any smaller.

The power of color: why are social media logos blue?

I gave a presentation recently at my new residency program about social media, and now I'm revamping it for a local physician group.  As I was tweaking my presentation, I began to realize that the images I had downloaded all featured blue.

Facebook.  Twitter.  LinkedIn.  Blogger.  Myspace.  Digg.

I'd wager that this similarity is no coincidence.  After all, marketers use color every day to subconsciously influence our perceptions of their brands.

My curiosity grew, and I started reading about the power of the color blue.  Here's what I learned:

"Blue appears to be a universally likable color." (1) 

"Blue invokes feelings of authority, expertise, eliteness, calmness and  trust....Blue is the colour of corporate America." (2) 

"Dark blue: trust, dignity, intelligence, authority.   Bright blue:  cleanliness, strength, dependability, coolness.   Light (sky) blue:  peace, serenity, ethereal, spiritual, infinity." (3) 

"Blue – Trust, security, peace, open, stability." (4)

Police and military dress uniforms are blue. (5)  Bank of America, Best Buy, Pepsi, Wal-Mart, ING, Ford, Merrill Lynch, Staples (6) - the more I look, the more blue I see.

I wonder if these social media sites settled on blue logos from the get-go, to push a message of authority and dependability even while they were so new?  Or, maybe, one of the first sites chose blue, and it somehow evolved into the universal social media color?  

Regardless of whether your organization wants to have a social media presence, it does; it's up to you who's in charge of it.  Similarly, your website's colors will influence your audience, and it's up to you whether you're in charge of that effect.

When I was setting up this blog, I settled on a neutral color scheme because I wanted my readers' focus on the text.  I never gave color any more thought.  When asked about how to start a blog, my responses never related to color and design.  I see the error of that omission now.

My updated advice to anyone designing a web space is to not neglect the visual appearance of your blog.  At the same time, a snazzy color scheme won't make up for a dearth of content, which is where the bulk of a blogger's energy should go in the long run.  For now, I'm sticking with my black and white.

But, you never know when I might succumb to the blues...

(1) Thanks, Quora:  http://www.quora.com/Why-are-most-social-networking-sites-blue
(2) http://www.tuned-in.com/ColorSpeaks/Blue.aspx
(3) http://www.colormatters.com/blue
(4) http://www.smallfuel.com/blog/entry/marketing-by-color-dont-try-to-sell-blue-potatoes
(5) http://www.evancarmichael.com/Small-Business-Consulting/965/Color-my-World--How-to-Use-Color-Effectively-in-your-Marketing.html
(6) http://www.smashingmagazine.com/2009/01/28/colors-in-corporate-branding-and-design/
Interesting round-up of all of the colors: http://www.precisionintermedia.com/color.html

The Stack

Medical folk, you know what I'm referring to: that ever-growing stack of journals that we'll all sit down and carefully read through "someday."

My stack of journals is about 3 inches high at this point.  When I am in the groove of efficiency, I take the time to flip through each journal when it arrives, tear out any articles that look interesting, and recycle the rest.  When the deluge of patient care and teaching and research and meetings overtakes me, the journals pile up unopened.

The Stack taunts me for my negligence.  The Stack generates guilt.  The Stack hisses "you can't keep up, you'll never keep up."

The Stack is right.  I can't keep up.  None of us can.  The medical literature machine cranks out hundreds of articles a week.  I do not have the hundreds of hours it would take to read even a fraction of them.  Accepting those facts is part of being a 21st century physician.  I don't want to abandon my effort to stay up-to-date with the literature, but I need a new strategy.  Piles of journals that only accumulate dust aren't helping anyone.

I don't mean to suggest that journals are unnecessary - far from it.  I just need a different way to digest them.  I do a decent job of keeping up with Twitter, RSS feeds, and e-mail "breaking news" alerts.   I also use DynaMed and other evidence-based tools on a daily basis.

While I respect those who like reading a paper journal, this electronic effort is working much better for me.  I'm usually one of the first of my colleagues to know about a new study or a practice change recommendation, and I'm adept at quickly answering point-of-care questions using my electronic tools.

So, I'm done.  Off go those unread journals to the recycle bin, and back I go to iGoogle, Twitter, InfoPOEMs, and the blogosphere.

I hereby declare myself free from The Stack.

Family Medicine Book Reviews - Coming Soon!

Sharing our stories can validate our frustrations, release pent-up emotion, and connect us to our colleagues.  At my old program, the residents had humanities sessions where they wrote 55-word stories,* composed their own personal medical oath, and even spoke with patient guests about the patient experience.

Most major medical journals now include a place in each edition for a narrative medicine piece; even JAMA has poetry and "A Piece of My Mind," both usually penned by docs, every other week.

At the FMEC Board meeting last month, our CEO Larry Bauer brought a huge stack of books written by family docs. (When I say "book," I am not referring to textbooks, but to other nonfiction, though I think there might be a novel or two in there as well.)  He remarked that many of these family physician authors released their titles with little fanfare from their Family Medicine colleagues or organizations.

I myself had no idea how many books family docs have written over the years.  As one of the leaders of our humanities curriculum at my old program, I would certainly have included some of these writings if I had only known about them.

I vowed to spread the word about these books, so I'm going to be presenting brief reviews of them over the next several months.  Perhaps you might find at least a couple of them worthy of a read for personal edification and/or curricular enrichment.

It's so easy, in this job, for empathy to erode under the weight of paperwork and productivity demands, not to mention that people are not always at their best when ill.  A brief period of time engaging in medical humanities - be it reading, journaling, or just talking - can be a gentle reminder of why we signed up for this calling.

So please stay tuned for these upcoming book reviews, which will be scattered in amongst my other usual musings.

*http://www.stfm.org/fmhub/fm2007/March/Joel169.pdf
acronym call-out:
FMEC = Family Medicine Education Consortium www.fmec.net
JAMA = Journal of the American Medical Association.  One of the, if not the, medical journal "biggies."

Stuck

My hairstylist here in my new city is very nice, but she's quieter than the vivacious and caring chatterbox that I left behind in my old city.  I feared that I'd never "click" with her; at every appointment, I found myself wishing I was back in my old city with my old stylist.

At my most recent appointment, I was able to pause in my melancholy thoughts long enough to realize that she's one cool chick.  I had been letting my connections to the past keep me from making a connection to the present.

I am stuck in the past, I realized, stuck grieving for the people and places I left behind when I moved here last fall.  I miss my old work colleagues, and I wonder how my patients are doing.  I miss the local restaurants that can't be duplicated here.  I miss knowing everyone in my old hospital, knowing every secret shortcut, knowing who could get what done for me fast.  I miss my cozy shoebox of an office that barely fit a desk and a small filing cabinet.

I'm tired of getting lost in the shiny behemoth of a hospital that I round in.  I haven't met many of the consultants yet, and rounding one week in six is not introducing me to the nurses and staff very quickly.  My new office space is larger than the one I left, with plenty of space for books and files and a big desk; the extra square footage, though, just makes me feel lost.

I'm beginning to worry that this grief is going on too long, that I am mentally there more than here.  Intellectually, I know that those connections in my old city and workplace took years to forge, and I know that much of that is just yet to develop here.  Don't get me wrong: I like much of what I see here.  It's just that the past is so seductively comfortable.

But the past is the past, and by mentally living there, I'm losing out on opportunities here.  I've got to figure out exactly what happened in the stylist's chair last week and keep letting it happen.

It's time to get unstuck.

Paronychia aftermath

Last month, I had a paronychia* in my left index finger's cuticle.  Thankfully, it never localized into a pus collection, so I was able to successfully treat it with just warm water soaks.

The new part of my nail is now growing out scarred and yellowed.   The tip of my finger was pretty swollen with this infection, so the nail also was forced to grow over the swelling, resulting in a sizable curve in the middle (it looks "clubbed," for you medical folk).  It is thin and weak, and the edges keep tearing on surfaces a normal nail should be impervious to - the edge of a mitten, the corner of a towel, the edge of a latex glove.

I don't consider myself a particularly appearance-obsessed person, but this unsightly, frayed nail bothers me.  I've come to realize that I use this finger quite frequently: I'll tap at papers with test results, computer screens with interesting information, my iPad to open a medical app.  I'm so self-conscious about this ugly nail that I am constantly checking to see if my patients and learners are looking at the nail instead of the information it's directing them to.

I don't want the nail to distract them, and, I have to admit, I don't want the nail to falsely suggest that I'm unhygienic or diseased in some way.  I don't like to paint my nails (too high maintenance for me), but I've considered it only to worry that the chemicals in the polish will weaken the nail further.  I tried covering it with a band-aid, but the medical people out there know how annoying band-aids are when you're washing your hands fifty times a day.

My rational self reminds me that it's unlikely anyone is paying much attention to the nail; it hasn't garnered one comment yet.  It does serve as yet another reminder that doctors are prone to the same annoyances of minor illness as every one else.  Like everyone else who's ever had a paronychia, too, I will just have to wait for a new nail to grow in.

Ah, yet another opportunity to cultivate patience.  *sigh*

* for non-medical readers: a paronychia is a cuticle infection.  Here's some cool (or gross, depending on your point of view) pics:
http://hardinmd.lib.uiowa.edu/dermnet/paronychia6.html
http://dermnetnz.org/fungal/paronychia.html

FMEC = Kick Ass Family Medicine!

I have the privilege of serving on the board of the Family Medicine Education Consortium as a member-at-large.

Who is the FMEC?  Well, we're a not-for-profit corporation that incubates ideas, connects people, and catalyzes healthcare change in the NE region of the US.  Our website states that we...

• Support programs and services that promote medical student interest in Family Medicine
• Stimulate the recruitment and development of Family Medicine faculty
• Facilitate relationships that lead to scholarly efforts relevant to Family Physicians
• Create coalitions among those who wish to increase the number of Family Physicians in the U.S. 

We also sponsor an annual meeting where 1000+ people interested in FM, or affiliated with FM programs, gather to network, present curricular innovations, and share clinical research.  The meeting also includes the second-largest annual residency fair in the country.
 
Nearly 300 medical students attended our meeting last year.  In many medical schools, Family Medicine is marginalized.  Students considering FM careers are frequently told that they are "too smart" to be a family doc.  At the annual FMEC meeting, students experience FM's vibrancy.   Their career plans are often set or affirmed; two-thirds of the students who attend eventually match in Family Medicine, and the rest comment that they have an new appreciation for their Family Medicine colleagues.


Every medical student who attends the meeting does so for free, minus the cost of transportation.  FMEC provides scholarships to cover their hotel rooms, conference fees, and all meals.  The generosity of corporate and individual donors covers the cost of these scholarships.
 
If you've not heard of the FMEC before, I invite you to learn more about us at www.fmec.net.  We believe in KAFM - Kick ass Family Medicine!  


Perhaps you might come to our annual meeting (this year in Cleveland, Sept 28-30) to present, host a booth at the residency fair, or just bask in the spirit of KAFM.  Perhaps you, or the folks you work with/for, might even be interested in sponsoring a student (or 2 or 10...) and/or one of our initiatives.*


The ultimate goal of the FMEC is a simple one - to improve the health of the people we serve.  Family docs can't afford to not participate in determining the future of health care in this country.  


We have a critically important voice to add to the conversation, and organizations like the FMEC help to broadcast that voice loud and clear.


* http://fmec.net/projects/index.php  Interested in knowing more?  Please send me a direct message on Twitter: @SingingPenDrJen or leave a request for more info below.   (I sponsored 2 scholarships last year myself, for the record.)

Not so much singing lately

My immune system has apparently been challenged by the microbes in my new city, as I'm now recovering from the second of two viruses I have caught in the last three weeks.  The first was a standard cold, and the second has been bronchitis.

With my asthma, I can't sing much at all when I'm sick.  Even mild stuff like I've had this past month sets off bronchospastic coughing fits, making singing very difficult.

I love to sing - in the car, in church, on a stage - wherever and however I can.  To not be able to sing feels like a connection between my inner emotion and outer expression has been severed.  I feel muted in a way that nothing else can replace.

For this introvert, singing is a way that I can push outside of myself while not feeling too vulnerable. When I sing for an audience, I am either portraying a character or worshiping God.  Neither is ultimately about me; lyric, tune, and purpose provide a comfortable buffer.

Writing is a solitary activity; I create it alone, and it's most likely read by my audience alone.  Singing instantly connects me with other people.  I suppose that I unconsciously pursued these two rather different skills to provide for different internal needs.  The energy release from writing is quiet and self-satisfying, while the release from singing has a louder, more cathartic power.

I realized this week (in between coughing spells) that my career mimics these different dimensions, too.  I have solitary encounters with patients and families, and I teach and present in groups.  The balance of personal and public in academic medicine is a good fit for me.

I also realized that, after a year of blogging, I've barely commented on the "Singing" part of the "Pen of Doctor Jen."  So, I'll try to share more of that piece of me from time to time.

Just as soon as the "Singing" comes back, that is.

Who's who in the medical training world

In my last post, I alluded to different levels of medical training.  As I thought about the post later, I remembered that many of the patients I've interacted with over the years are confused about what those terms mean, and perhaps some of my lay readers are, too.

So, today I present the Singing Pen's guide to medical seniority:

Medical student = has completed a bachelor's (college) degree and is in a 4 year medical school program.  Medical students cannot independently provide any patient care; their patient notes and orders must be co-signed by a licensed physician (can be a resident or an attending).

Resident = has graduated from medical school and is training in his or her medical specialty of choice.  Residents must have medical licenses to practice and train, and a resident is rightfully referred to as "Doctor."  Graduating from medical school does not confer enough knowledge to practice independently in this day and age, though.*  Specialty training programs thus follow medical school for virtually all US med school grads; those programs are called "residencies" because, in the old days, residents actually lived (resided) in the hospital.

Intern = a first year resident.  This term is falling out of favor in some circles, as some residents and their teachers worry that it has developed a demeaning connotation.  The label persists partially because it's convenient (interns require the most supervision of all residents, given that they're fresh out of medical school) and partially because some medical specialties require a generic ("transitional") intern year program before joining their residency program (ophthalmology and physical med & rehab are two examples).

Fellow = a post-residency trainee.  Most residents go directly into independent practice after completing their residency, but some medical career paths require yet more training.  Many of the internal medicine specialities require fellowships: cardiology, endocrinology, nephrology, rheumatology, as do some of the surgical subspecialties.  Some fellowships focus less on patient care and more on academic training; I did a two-year faculty development fellowship following my family medicine residency to build my teaching and research skills.

Attending = done with training (but certainly never done with learning)!  Attendings bear the final responsibility for the trainees working with them.  Many attendings don't teach at all and just work independently, but those of us in academia work with students, residents, and fellows on a regular basis.

So, from the last educational level to the earliest:
Attending
Fellow
Resident
(Intern)
Medical student

Each level has responsibility to the levels below.  So, residents supervise medical students and attendings supervise residents' supervision of the medical students. As residency takes 3-6 years, depending on the specialty, higher-year (or "senior") residents often supervise newer residents ("junior" residents and/or interns, depending how each residency program labels its residents).

Some residency programs designate one, some, or all of their final-year residents as "chief residents" with varying levels of responsibility - from scheduling to teaching to representation - for their resident peers.  In many programs, being a chief resident is an elected honor.

Each year of medical school and then residency confers more responsibility and autonomy, ideally with the attending safety net always easily accessible.  Good attendings unobtrusively know everything that's going on with both the patients and their learners.  They gently guide the plan of care in the right direction, liberally sprinkle in teaching points, and avoid micro-managing every little detail.

I don't want to suggest, however, that the learning only moves in one direction. The constant challenge of keeping up with the latest evidence and studies is an energizing part of the job for many of us.  I learn more from the ideas and perspectives of the residents and students I am privileged to work with than I could ever teach them back.  This two-way learning makes academic medicine a very interesting place to be.

I consider myself one fortunate doc to get to teach every day, that's for sure.

* "General practice" as it used to be known in the US is no more.  Many family docs and internal med docs are frankly offended when people refer to them as a "general practitioner" or "g.p.," as these terms imply that their medical training ended after medical school (which used to be the case decades ago).  The vast majority of primary care docs in the US are board-certified "specialists" who have completed residencies in either family medicine, internal medicine, or pediatrics.

Patient comments about my age

I have gotten some interesting comments from patients regarding my age.

When I was a medical student, patients thought I was in high school.  When I was a resident, patients thought I was a college student.  Now, as an attending over five years out of residency, I get comments like "you sure know a lot for someone so young," well-intended compliments meant toward the resident I apparently appear to be.

An enviable problem to have, right?  Except I would like my patients' initial impression of me to be "professional and competent," not "nice and young."  I fear that patients will not trust me to manage their care if they think I'm so inexperienced.  I want them to have confidence in the recommendations I give them and the decisions we make together.  I have to admit, too, that a part of me wants my current station on the top of the medical training ladder to be acknowledged.

I wish it wasn't so, but it's true: I need my patients' affirmation as much as they may be looking for mine.  I'm ashamed of that confession; patients' duties should not include validating my insecurities.  I suspect, though, that I am not alone in constantly worrying about whether I am doing my best for my patients.

It's not so easy to evaluate your performance as a doctor, either.  No one is directly evaluating us, and the popular markers of success - productivity, income, government ratings - don't reflect the bulk of what our care with patients truly involves.   Patient satisfaction scores only go so far, since disgruntled patients can result when we correctly turn down unreasonable requests.  Quality improvement measures are a step in the right direction (1) but still don't answer the basic question: "did I follow the best path for this patient?"

It's all too easy to fall back on those numbers and patient affirmations to judge myself.  They each have their place in the overall picture of my practice, but I've got to center my focus on patient care where it belongs.

Just like the responsible 36-year-old I am.

(1) http://www.who.int/patientsafety/education/curriculum/who_mc_topic-7.pdf

Oliver the Cat

Have a dog, cat, or other pet at home?

Pet ownership is good for your health.  Petting a furry animal can decrease your blood pressure and stress.  Dogs are notorious for dragging their owners outside for exercise, and goldfish can be quite calming to watch. (1)

I can testify that pets are also a great help for loneliness.  When I moved to a new city for residency eight-and-a-half years ago, I was still unmarried and didn't know a single person there. Every night, my cats Mr. Tig and Oliver the Cat came to my apartment door to greet me when I got home.  They didn't care about the mistakes I had made that day, they didn't care if I was stinky from 24 hours on call, and they didn't care about my rumpled scrubs. They just loved me unconditionally, content to sit on my lap while I watched mindless television, talked on the phone, or even, occasionally, when I needed a good cry.

Those cats were my soul's balm during medical school, residency, and fellowship. They moved three times with me over those years, and their presence in the early days each time was a tremendous comfort.

Unfortunately, though, no pet lives forever.  Oliver the Cat starting losing a lot of weight about 6 months ago.  His CBC, splenomegaly, and weight loss spelled out a pretty clear picture for his human doctor owners, and we decided against any further, more aggressive work-up.  We didn't want to make him suffer through more tests and likely chemo just to squeeze out a few more months for ourselves with him.  His vets wholeheartedly agreed with our decision.

He ate less every day, and he spent increasingly more time on a soft rug in a warm downstairs bathroom.  Tig, previously inseparable from him, started keeping his distance, perhaps in recognition of Oliver's instinct for peace and quiet during the dying process.  My husband and I visited him several times a day and tried not to think of what was surely coming.

Three weeks ago, though, less than an hour after my husband and I had gotten home from work, Oliver died in my arms.

Pet grief is real grief. (2,3)  My husband keeps commenting on how empty the house feels, and Tig keeps peeking into that downstairs bathroom looking for his buddy.  I'm having trouble getting out of bed in the morning and concentrating at work.

I don't want to let the sadness trump all of the good times I had with Oliver.  I'm grateful for his presence in my life during our eleven years together, and I have lots of funny and sweet memories of him to cherish.  

Being a pet owner myself, it's been easy to ask my patients about their pets.  I keep track of my patients' pets in their charts and inquire about them occasionally. Knowing that patients with tough situations have a furry (or scaly or feathered) friend at home always eases my worry about them.  I have shared in my patients' grief over their own pet losses many times as well.  The discussions usually follow a similar outline; they share memories, I make some remarks, and then the conversation always closes with the same sentiment:

We wouldn't trade the time we had with them for anything.

(1) http://www.cdc.gov/healthypets/health_benefits.htm
(2) http://www.questia.com/googleScholar.qst?docId=5001975384
(3) http://guilfordjournals.com/doi/abs/10.1521/bumc.2009.73.3.176

And, a nice post about coping after the loss of a cat: http://cats.about.com/cs/copingwithloss/a/de

Dammit Jim! I’m a Doctor, Not an Engineer

Happy New Year from the Singing Pen.   I'd like to kick off the 2012 blogging year with a guest post by my father, Mr. Victor Middleton, who is, in fact, an engineer....

Dr. Jen, a Star Trek fan, has been known to quote Dr. McCoy’s dictum (lament or boast depending on your point of view) to her brother James whenever she requires assistance with recalcitrant computers. I am an engineer, and I find this plaint typical of the gulf between our respective professions. Doctors tend to view us as overseers of useful but often-wayward tools.  Doctors practice the art of medicine; engineers are mechanics who help take care of support details.

I’m writing this piece to try and modify that point of view and to urge a closer interaction between medicine and my particular flavor of engineering.  What I do can be classified as systems engineering or industrial engineering, or, as I prefer, operations research (OR) engineering.  

OR practitioners are dedicated to improving the operation of systems of all sorts, whether they are organizational practices and procedures, manual processes, mechanical controls and devices, computer software, or combinations of all of these.  OR as a discipline traces its origins back to World War II when engineers and mathematicians were asked to help optimize resources, including personnel and materiel, for maximum military effect. OR groups attached to the British Anti-Aircraft Command were charged with the improvement in deployment and use of Britain’s new radar network and helped win the Battle of Britain; similar groups developed novel submarine search and engagement procedures to defeat German U-boats in the North Atlantic.

The key phrase above is the “optimize resources, including personnel and materiel.”  It is incontrovertible that the health care system in the US today needs to do a much better job with respect to utilization of resources on virtually all fronts, from matters of national policy to local hospitals and health care providers.  We OR engineers can help.  

Even a cursory Internet search on health care and operations research will display a wide spectrum of ways in which OR can help docs and other health care providers, saving money through more efficient operation, but, more importantly, helping to optimize patient health care outcomes.  It would be futile for me to try to describe the extent of OR applications to health care here, but I would like to mention a few overarching principles. 

First, OR is a systems science that seeks to integrate local capabilities into more global solutions.  How do emergency room practices affect operating room availability?  How does scheduling for elective procedures affect overall hospital bed occupancy?  How must vaccination and treatment protocols be adjusted to deal with the differences between local disease outbreaks and the potential for deliberate terrorist attack?  Perhaps the best example for Dr. Jen and her colleagues would be: how does the family practice doctor help coordinate general health issues with specialist care?

Next, OR and industrial engineering seek to look at the role of systems in preventing errors.  The medical profession tends to view error as attributable to mistakes by individual practitioners.  Since we have as yet been unsuccessful in developing fail-proof individuals, a far more fruitful ground for eliminating errors is developing systems that first help avoid errors and that help identify them and mitigate them when they do occur.  Such a systems approach encompasses everything from human factors design of automated data entry and retrieval, to computer diagnostic aids, to more efficient training and re-training, and to the development of redundant procedures that check and double-check the appropriateness of treatment.

Finally, I would like to note that as engineers we share an ethical bond with physicians and their mandate: “Primum non nocere.”  As engineers, we are not impartial scientists objectively studying natural phenomena to see what makes the world tick.  Our job is to make changes to that world, and thus our ethical responsibility is to ensure that we change it for the better.  I can think of no better way to meet this responsibility than joining with medical community to address the health care needs of our country and each individual in it.

Interested readers are urged to search the Internet.  A small sample includes:

http://www.orms-today.org/orms-4-02/frmismanagement.html

http://www.wtec.org/or/report/OR-report.pdf

http://onlinelibrary.wiley.com/doi/10.1111/j.1475-3995.2010.00767.x/pdf

http://currentadvances.org/images/OrthopaedicSurgery/16_RedefineCompetition.pdf

(This last, while strictly speaking not OR, certainly expresses an OR perspective on the problems with the health care system in the U.S.)