As a primary care physician with a special interest in tackling obesity, I spend a large portion of my day pointing out the obstacles between my patients and a healthier lifestyle. In the United States, these stumbling blocks are everywhere and often cloaked in legitimacy by people or groups that hold sway over consumer confidence. Say, for instance, the placement of …
A transition to a lollipop-free clinic
As a general internist who has been on the front lines of adult primary care for over twenty-five years, it is clear to me that we are living witnesses to a major and rapid transformation in medical care delivery. When Paul Starr published The Social Transformation of American Medicine in 1982, his work covered gradual changes over a 200 year period. We now live in a fast paced world where …
Primary care is in decline, and it’s easy to see why
Like a lot of people, I get pretty numbed to gun violence on television. I stopped watching the local news because all they seem to show is news about shootings. The general public’s perception about gun violence is that it’s always somebody else, that the person who was shot had somehow been involved in crime. The numbness we feel to gun violence often ends for most of us when things …
How can we reduce firearm-related deaths? Here are 6 ways.
Humans are social creatures who naturally evaluate where they stand in relation to those around them. I have no idea how this evaluation process evolved, but at some point we noticed that some cavemen brought more food to the cave than others. The idea was born that some people are better hunters than others. We’ve been trying to decide who is “better” ever since.
The origin of the word “test” comes …
Tests in medicine and public schools: What do they really measure?
They say that there may be children, born now, who could live to be 1,000 years old. Can you fathom that? Some humans could continue to live for what would be well more than ten current lifetimes. We aren’t there yet. But this isn’t so far out of the possible. Some medical researchers are already talking about resuscitating those who die up to five hours after death. It involves special …
Grandparents who spend their old age raising their grandchildren
As a primary care provider practicing in the safety net, I work with incredibly diverse patients with chronic illness. My patients have a wide range of beliefs and preferences about how to best manage their health. I believe their varied perspectives, if more widely shared, could meaningfully improve health care.
I also do research on health information technology, and in that sphere I have listened to talks and spoken with many …
From e-patients to all patients
I had two experiences recently that reminded me that many doctors and nurses remain resistant to measuring and improving how patients experience the care we provide. One was a face-to-face discussion with a senior physician. The other was reading an article by a nurse. Both the doctor and the nurse denounced the growing focus on the patient experience by citing the threat to the quality of care, and I believe …
In support of measuring patient satisfaction
LabCorp, one of the largest outpatient lab providers in the USA, is soon going to let you skip the tedium of a doctor’s visit to get lab work done. Want some tests? Come on down!
I’ve got mixed feelings about this. While there are some tests that seem reasonable for people to do on their own — pregnancy and HIV tests come …
Order your own lab tests. What could go wrong?
Imagine patient-centered care explained as a kind of updated Norman Rockwell painting. What you’d get is a recent PBS documentary, Rx: The Quiet Revolution, which, yes, uses a famous Rockwell image of a kindly family physician (Doctor and Doll) to set the stage for what follows.
Putting patient-centeredness into practice
The 90-minute film, available for viewing online, features four extraordinary stories of inspiring health care providers working in Maine, Mississippi, Alaska …
Putting patient-centeredness into practice
Scalability is the end goal of nearly every tech start-up, systems innovation, and teenager you-tubing their cat — it’s going viral, business-style. And traditionally, it’s been seen as a marker of relevance and success. Growth is good, right?
But in health care systems transformation, do we lose something meaningful when we measure the value of our work by its national impact?
Take Iora Health, a new health …
Health care transformation is local: The problem with scaling Iora Health
One night while on call, I was sitting in a loud downtown restaurant when I received a phone call from the hospital. I didn’t think I would be able to hear the call, and so I scurried around to find a place to speak. The bathroom appeared straight ahead, so I rushed into the first empty stall, locked the door and took the phone call. After wrapping up with the …
Primary care: Easing trepidation is a full-time job
In this age of Internet-everything, online reviews have become the par for the course for business, and this includes medicine. Indeed, one recent survey found that 88 percent of consumers trust online reviews as much as personal recommendations. So online reviews count. And overall, this is a good thing. Data shows that more reviews translate into significantly more appointments, and this holds true even if some …
A physician gets a bad online review. What next?
Going into my final few months of residency, I am somewhat puzzled, knowing that so many of my colleagues are signing contracts with hospital-owned outpatient practices, going into subspecialist fellowship training, or having plans to work as a hospitalist. As someone who plans to go into solo private practice, I feel like an outlier.
Yes, I know what you might be thinking. Who goes into solo practice these days when hospitals …
Is starting a private practice a dying art?
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Here are ten ways that Internet diagnosing interferes with your health care.
1. Dr. Google doesn’t know you. Can’t see you, can’t hear your story, can’t smell you, and can’t touch you. It doesn’t have intuition or gut feelings about you.
2. The Internet breeds cyberchondria in some and false reassurance in others. The more complex the problem, the more likely your self-diagnosis …
Dr. Google will never know you or care as much as I do
I see some odd things in my clinic. One recent diagnostic dilemma was a man in his late fifties with shortness of breath.
He had been born with a ventricular septal defect and had undergone surgery for this in his infancy. During his lifetime, he had seldom gone to doctors and always thought he was in fairly good health, maybe just of a weak constitution. A smoker since age 13, he …
A rare case in a rural doctor’s office
The recent killing of Walter Scott was another brutal reminder of the home African-Americans wake to daily. Their America, is one where your father might not come home at night, because his brake light went out, and that cost him his life. It’s a place where petty crimes are penalized by life sentences, doled out on the streets by the very men and women charged with their …
Walter Scott and a physician’s conscience
JAMA published an opinion piece about the controversial issue of patients secretly recording their physicians during encounters. We live in the era of the smartphone. Everyone has one — soccer moms, teenagers, young kids who can’t even read yet, elderly nursing home patients who can’t safely feed themselves. Everyone. And these devices have amazing powers of audiovisual capability. We all know this. …
When is it OK to secretly record your doctor?
It has been known for a long time that “health care” — all the stuff that we do, prescribe and provide — is a minor determinant of how “healthy” any of us is. Overall health, or more technically, the variability in health outcomes, is much more dependent on the combination of genetics, personal behavior (think smoking and seat belts), environmental factors and socioeconomic status than it is on health care.
I …
Why it’s time to improve the social determinants of health
A few weeks ago I wrote a piece about performance metrics in medicine. People asked me: “Well, if you don’t like the metrics, what would you use?” So I thought about this, and the best way I can think of to explain what I mean is to use an example from a different field: education.
Standardized testing has become ubiquitous in schools. …
Doctoring to the test. Look to education for a cautionary tale.
On Monday March 30, 2015 our Greenway PrimeSuite electronic health record had a system-wide failure at the level of the Edgemed Computer service center in New York State. It meant that I was back to using pencil and paper to interview patients and record the answers and physical findings.
With much trepidation, I began seeing patients with two sheets of white blank …
I temporarily went back to paper records. And it wasn’t so bad.
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