It was just a regular hot and humid Saturday morning in Miami, and I was on my way out of a local Walmart after buying a few items. As I walked to my car at the end of the parking lot, I heard a voice asking me “Son, any change?” In a neighborhood that is known to have a disproportionately large amount of vagrants, I did what I usually do …
The civic responsibility of physicians in our community
“Robert Loeb was the best damned ethicist I ever met.”
When I first heard a senior colleague of mine utter these words in the mid-1990s, I was surprised. Time had not been particularly kind to Loeb, who had been the chairman of medicine at Columbia-Presbyterian Medical Center from 1947 to 1960. Among other things, critics had chastised Loeb for being imperious and unwilling to listen; former students had even accused him …
Ethical physicians, now and then
As a medical student I was in awe when a professor looked at a patient’s hands or nail beds and described their medical condition without taking a history. I was also enthralled by a TED talk by the best selling author, Abraham Verghese, where he described a lesson that Arthur Conan Doyle, author of Sherlock Holmes, learned as a medical student at the medical school in Edinburgh, Scotland from the famous …
Estimating a patient’s age-clinical implications
Mr. Katz sat on the edge of his chair in my clinic room, teetering as if he might fall at any moment. He was 86-years-old, and his thin body had become weak and tired. But his angry eyes, like a petulant child, stared at me.
“Doc, you should have just let me die,” he said to break the ice.
I had just discharged Mr. Katz earlier in the week from the hospital. …
How physical therapy gave an elderly patient hope
As a new physician, I find myself besieged by data about how happy patients are with the care we deliver. Press Ganey, HCAPS, Consumer Reports, US News and World Report were merely the beginning.
Now, physician reimbursement is tied to how happy patients are after facing and overcoming, at times, life-threatening illnesses in our hospitals. Given the financial incentive, hospitals across the country are seeking the aid of companies like Disney: well-known …
Don’t mistake patient satisfaction for patient-centeredness
Over the years, my husband’s parents, Helen and Dave, have both suffered unnecessarily from bad medical care. They are not alone.
A botched cataract surgery left Helen with a torn iris. One of her eyes can’t adjust to light, and for the last several years she’s worn sunglasses indoors. Her urologist kept treating her with the same antibiotic for urinary tract infections without testing to see what bacteria she had. When …
We should value quality when we shop for health care
A few months ago, the father of a primary care physician came into the emergency department with syncope. He was 102 years old. His age was more than double his heart rate. That may or may not be bad but it certainly is often a reason for more testing. The senior resident seeing the patient ordered an EKG, a battery of labs, a head scan, and anticipated admitting the patient …
We need more clinical time outs
When I first met Ralph, he was 82-years-old. He suffered from shortness of breath which started when his wife of 56 years was diagnosed with a rare bone cancer. Upon further investigation, I diagnosed him with a weak heart and a very tight aortic valve which required immediate surgery. Ralph made it; his wife died. Today, twelve years later, he brings me treasures from his metal detecting hobby on the …
I read an article in the Boston Globe about how doctors are flocking to get Master of Business Administration (MBA) degrees in record numbers. The prestigious program at the Massachusetts Institute of Technology, MIT, apparently now has more students from the health care sector than any other field — accounting for almost 20 percent of the class.
A large number of these …
We need fewer doctor MBAs and more doctor healers
In an effort to save on human resources costs, some hospitals have decided to make locum tenens* doctors and nurses line items in a supply list. Next to IV tubing, liquid nutritional supplements and anti-bacterial wipes you’ll find slots for nurses, surgeons, and hospitalist positions.
This depressing commoditization of professional staffing is a new trend in health care promoted by software companies promising to solve staffing shortages with vendor management systems (VMS). In …
The problem with vendor management systems to solve staffing shortages
After I graduated from medical school, my very first real ward rotation as an internal medicine intern was at the VA. Therefore, I can say with absolute certainty that all the stuff being said about the VA health system is true. The place is a mess.
Let’s start with the computer system. The VA medical record system has been held up as an example of an effective EMR system, in which …
Our veterans deserve so much better than the VA
Carrie is a 72-year-old retired real estate agent with a high school education. She raised three kids, but they do not talk to her anymore. Since her husband died, Carrie has lived alone. A melanoma was removed from her right shoulder 2 years ago. In my office, we stare at the CT scan display of a mass in her right lung.
“What does that mean?”
“Well, we wouldn’t know for sure until …
Has abolishing medical paternalism gone too far?
The prevailing sentiment in pop-culture nutrition — propagated in books, blogs, and blather; documentaries and diatribes — is that everything we thought we knew about diet and health until yesterday is wrong.
Actually, we have a much bigger problem than that. To one degree or another, everything we thought we knew about nutrition is right — and we are obligated to do something about it, or stay fat and sick.
That’s …
Deeply worried about our dietary doom
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Recently in one of the Johns Hopkins Hospital’s intensive care units, a patient was dying from cancer and sepsis, and there was nothing that I, nurse Mandy Schwartz or anyone else could do to stop it. Yet as the patient’s family — two daughters and a husband — suffered at her bedside, Mandy saw their need for comfort, and she responded. Although she was busy with nursing tasks, she delved …
Health care is too nuanced for lengthy scripts
After I left my position as a staffer for the U.S. Preventive Services Task Force in November 2010, it was three years before I was tapped for another guideline post, this time at the American Academy of Family Physicians. Recently I joined the AAFP’s Commission on Health of the Public and Science, which formulates guidance for family physicians on a variety of topics, including clinical preventive services. My appointment coincided …
Can conflicting guidelines be good for patients?
I have long been a fan of the Case Records of the Massachusetts General Hospital, which is published weekly in the New England Journal of Medicine. For many years, I made a point of recommending them to medical students and internal medicine residents as a model of concise yet comprehensive case presentations.
No wasted words, no missing information, and none of the filler that trainees often added when they presented cases, such …
Be personable and make a huge difference in a patient’s recovery
Painful wait times at the doctor’s office. It’s an old story with few exceptions.
As a dad, I have to deal with many of the same issues of parenting that you deal with: sleepless nights , fevers and holding my kids down for shots (my wife did it once, I think, then she promptly retired from this job). However, waiting at the pediatrician is not something I have to do. So, I can’t truly empathize …
Reasons why your wait time at the doctor’s office is so long
Next in a series.
Years ago while in oncology training, I was on night duty when a patient of one of my colleagues was having severe penile pain. He had received a new investigational chemotherapy and it turned out to have an unexpected property of damaging the lining of the bladder and urethra. It gave him a strong uncontrollable urge to urinate yet each time the burning was excruciating. Oral …
Nonjudgmental listening is the first step in healing
Palliative surgery is tough stuff. Nobody wins much, and it often challenges one’s ability to think clearly, let alone to tell the truth. Sometimes, I think, it borders on the deceptive; it makes me wonder who’s the object of comfort. And yet, when there’s nothing else to do, it’s often just the right thing. I hate it.
To be clear: We’re talking about surgery to relieve some sort of specific problem, …
Palliative surgery: A surgeon reflects
It is unethical not to be compassionate when you are a physician. Treating people or their families poorly isn’t helpful to anyone in a stressful situation. But a big problem exists there – ethics is not taught in medical school. Then again, neither is compassion. So where do you learn them? Can you learn compassion, or is it something you just have?
Or don’t have?
She could have been anyone’s grandmother. White …
Watching people die is sometimes the compassionate thing to do
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