My blog represents my personal experiences and perspectives. This includes many anecdotes from my life and from my medical practice. I have been scrupulous to anonymize all medical anecdotes and to avoid ever belittling or making fun of patients. (I often make fun of and criticize myself, my colleagues, and the institutions where I have worked.)
I find myself a stranger in a strange land, or (more prosaically) a square peg being forced into a round hole.
I was recently told that ‘the problem’ underlying my often strained relationship with the institution where I work is that I am a revolutionary working in an institution committed to incrementalism.
What would you think if you received this message from management: “You can ignore chlamydia…it is not one of the quality goals for this year.” Or if you were told at a meeting to discuss a mandated quality initiative: “All you have to do to get credit for BMI screening is just click the box that says you will talk about it at the next visit.” (These are both true stories.)
Forty four good years, with more to come. I’ll honor it with the words we started with…
I don’t consider myself a laborer, though I surely work very hard. I work because I love to.
“No man needs sympathy because he has to work, because he has a burden to carry. Far and away the best prize that life offers is the chance to work hard at work worth doing.” (Theodore Roosevelt)
“Each morning sees some task begin,
Each evening sees it close;
Something attempted, some done,
Has earned a night’s repose.”
(Henry Wadsworth Longfellow)
'Taking a history’ is one of the first clinical tasks medical students are taught. The logic behind this is inescapable: without the history, attempts at diagnosis and treatment are doomed to failure. We start our training with the history, when we present patients for discussion with other doctors (in training or later, in practice) we start with the history. And except in rare emergencies, we start every patient interaction with the history. The history: it always starts there but it doesn’t end there.
The appointment was for his annual physical, and to review his well controlled hypertension and gout. After we had addressed these issues, I asked if there was anything else he was concerned about.
Having problems is not a problem. Believing or pretending there are no problems, and then punishing or marginalizing those who want to fix the problems - THAT is a problem.
In a previous post I talked about some important questions I ask myself in my attempt to avoid missing the correct diagnosis.
There is also a set of questions I like to ask the patient, usually at the conclusion of the visit while I am typing our collaborative assessment and plan into the EHR, to ensure that the patient and I are literally on the same page.
I have a serious problem with the ubiquitous use of 'due' when talking with patients about what their medical options are. This came up recently when I was given a list of my patients who were ‘due’ for certain services, required if my institution is to receive a financial quality incentive. Typically, ‘due’ shows up in EHR alerts (the diabetic patient is 'due' for their A1c or microalbumin) and quality programs (patients are 'due' for a mammogram every 2 years, a DXA at 65, a pneumovax at 65, even well child visits at set intervals).