Dustin Ouellete grew up a bit the other day.
I had known Dustin as an infant, and his mother before that. Several years ago, the Ouellete family moved away to the big city, but last summer they came back.
Dustin came in a few times with his father, and his main concern was migraines. Dustin’s father, a quiet man who seldom smiles, was concerned that the headaches were keeping his son from …
The day a young patient took charge and grew up
“I should be home well before nine o’clock,” I said to my wife on the phone as I steered my eight-cylinder SUV quietly down the highway at 75 mph with more than 100 miles left to go.
“More like eight fifty-five,” I added.
“That’s well before nine?” She sounded both weary and incredulous. I knew what she meant. I am not as obsessive about time as I used to be, but even …
We have a problem in our clinic.
Between our EMR implementation a few years ago and our PCMH recognition shortly after that, our office visit documentation has become bloated and our cycle time has almost doubled.
There are no brief visits anymore, since every visit entails screening for multiple psychosocial conditions and consideration of various immunization and health maintenance reminders.
Nobody sees over thirty patients a day anymore; we’re lucky to exceed twenty.
That …
Medical homes weren’t supposed to be this way. What went wrong?
Physicians play many roles in patients’ health care and lives in general.
In one encounter we may be the only one encouraging a hesitant or discouraged person to look inside and outside themselves for the strength to move forward with a difficult decision.
In the very next appointment, we may be taking charge as a patient develops chest pain and shortness of breath in front of our eyes.
We sometimes find ourselves in …
Do doctors reveal too much about themselves?
A woman in her mid-thirties with a terrible limp and a past surgical history in the dozens became my patient two years ago. Her prosthetic left leg served her well, but her right leg was moving awkwardly because of advanced hip arthritis and a formerly shattered ankle.
She was on long-acting morphine and short acting oxycodone. Her Social Security disability insurance didn’t cover the long-acting form of oxycodone.
She told me several …
A family physician duped by a patient on chronic opioids
“One of the most prominent definitions describes burnout ‘as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity.'”
– Maslach, Jackson & Leiter, 1996
In 1974, the year I started medical school back in Sweden, the German-born American psychologist Herbert Freudenberger published a journal article titled “Staff Burnout.” In it, he wrote about the physical and emotional symptoms of …
Burnout is a consequence of the deprofessionalization of medicine
Dear health care administrator,
I am writing to you in a spirit of cooperation, because the way health care works today, it is too complex a business to manage on the side while also taking care of patients. And I hope you don’t have any illusions about medicine being so simple that non-physicians like yourself can manage patients’ health care without trained professionals who understand medical science and can adapt the …
Dear health care administrator: Physicians are your friends
Back in my first year of blogging, I wrote a post, titled “A Day Without a Diagnosis,” about the way we now spend most of our time “managing” chronic diseases, some of which weren’t even considered diseases when I went to medical school.
That’s not how all my days go nowadays: A week ago I had a day of some very real doctoring.
My first patient of the day was …
A refreshing day of real doctoring
Physicians today are increasingly viewed and treated as skilled workers instead of professionals. The difference is fundamental and lies at the root of today’s epidemic of physician burnout.
Historically, there have been three learned professions: law, medicine, and theology. These were occupations associated with extensive learning, regulation by associations of their peers, and adherence to strong ethical principles, providing objective counsel and service for others.
Learned professionals have, over many centuries, worked …
Doctors are more than just skilled workers. Here’s why.
77-year-old Edward Tripp had been to the emergency room with chest pain last Friday night. It was relentless, aching, and involved the upper part of his left chest.
He had no cough, fever or shortness of breath. He was not sweaty or nauseous, and his blood work, EKG and chest x-ray were normal. He was distinctly tender over the part of his rib cage where bone and cartilage join each other …
Medicine is often more complicated than the first positive finding
When I started my first internship, back in Sweden in 1979, I worked under a fifty-something cardiologist who spoke slowly with a southern drawl — yes, there is a southern drawl there, too, slightly reminiscent of Danish, spoken not far from where my supervisor grew up.
He epitomized the old school of cardiology, before it became a procedural specialty. He diagnosed heart murmurs by auscultation with his stethoscope, and he even …
Will cardiologists become slow and methodical internists again?
Today I met a man who wanted to interview me before transferring his records.
He was about my age and seemed polite and pleasant enough. He told me his doctor of a dozen years had started to taper him off his long-term narcotics after he reported some of them missing because of theft. He used to take the equivalent of about 1,200 mg of morphine per day for his back pain. …
The interview before transferring to a new doctor
Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the government and corporate America want them to have.
Up until this point, the momentum has been with the payers, Medicare, and the insurance industry. But the more heavy-handed they become, the more inevitable the public backlash …
The straight face test of our health care system
Every primary care physician has had this experience: We refer a patient to a cardiologist, pulmonologist or gastroenterologist and get a note back that says our patient’s symptoms are not cardiac, pulmonary or GI related. “Not my department,” in essence.
Medical specialties are organized by organ or organ system, and not by symptom. This really leaves primary care doctors in the default role of being specialists in diagnostics. I often say …
Primary care doctors are specialists in diagnostics
Dear Santa,
I’ve been a very good doctor all year. I have checked all my boxes and aced all my meaningful use requirements. This year, I’m not asking you for anything fancy. I just thought you might be able to instill some kindness and good will into the people who designed the user interface of my EMR. Maybe, with your help, they would come to see how a few minor tweaks …
7 Christmas wishes for electronic medical records
The clues are usually there, even in the hardest of cases. They just aren’t presented to you on a silver platter.
Gwen Stephenson had an ill-defined polyarthritis and had been on methotrexate for some time. Her rheumatologist, Norm Fahler, had tapered her off the medication while keeping an eye on her inflammatory markers and they had leveled off at just above the normal range.
Seven or eight years ago, Gwen had suffered …
A low-grade fever that humbled this physician
When a wife suddenly comes in for her husband’s appointment, I usually worry a little; when a husband shows up for his wife’s visit, I sometimes worry a lot.
I have come to expect that when I enter an exam room, and a male patient has his wife with him in the room, she is there to make sure I hear some part of his symptom history that he has never …
What worries me about husbands and wives in the exam room
Twenty years ago, I changed the name and focus of the annual physical I offered my patients. I designed a new form on my laptop with Geoworks, my favorite DOS-based (pre-Windows) desktop publishing program, and rolled out my “annual health review.”
I explained to patients that many of the things we used to do in routine physicals every year had proven to be of little value, but there were more and …
How Medicare ruined the annual physical
From ancient times, doctors have appreciated that, for all their similarities, no two patients are exactly alike. This understanding is what made physicians act like, and earn society’s respect as, professionals.
The commercialization of health care has brought in managers from other industries and other branches of academia, and their rise to power has been predicated on their ability to treat patients and doctors not as individuals, but as small cogs …
It’s time to stop comparing health care to manufacturing
A long, long time ago, hospitals existed to admit patients when they were sick, treat them with medicines or surgery and good nursing care, and discharge them after they became well.
Hospital care was at one time a charity, which evolved into a nonprofit service, before it became a very big business.
In olden days, nonprofit hospitals charged patients straightforward fees for their services. Then, when you were just a young whippersnapper …
Readmission penalties: Medicare’s ingenious move
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