Mea sententia

It’s about the patient. All about the patient. Only about the patient.

I just don’t understand the way we order radiologic tests and procedures. 

If I discover skin cancer during an office visit, I refer the patient to the dermatologist or surgeon for evaluation and treatment. I don’t have to order the specific procedure they will do, or fill out a prior authorization form for their biopsy or excision.

Doctors often complain that patients indulge in maladaptive magical thinking and talk about how hard it is to get them to face reality. Sometimes, it is easier to join patients in their magical thinking.

I remember an incident from an Emergency Medicine clerkship during my fourth year of medical school. I was asked to see an agitated young man whose ED chart said: “Chest pain, agitation, hallucinations.”

Three years and ~ 250 posts ago I started doing this, wondering if I would be able to find things to write about. As it turns out, that was the wrong question. A better question would have been, would I care enough to keep writing. So far, the answer is a resounding yes. My plan for the next year is to keep questioning so I can keep learning and growing. The future has a way of sneaking up on us like a windshield on a bug.

I hope you all have a wonder-full New Year, and that all your answers lead to better questions.

Peter

Anne came in for her annual health maintenance visit with great news. Her irritable bowel syndrome was no longer a problem. “I hope you aren’t upset with me, but I’m cured.”

I miss the relative simplicity and patient-centeredness that characterized the early years of my medical career.

Decades of behavioral economics research and management science predict that framing quality of medical care as something that can be captured effectively by a simple metric, and then incentivized by financial rewards or punishment based on that metric, would misfire.

I find it disheartening that those who push for QI and P4P programs based on evidence do not understand the most basic principles of the scientific method.

Patient-centered shared decision-making is one of the toughest tasks in clinical medicine. It involves a collaborative effort to collect and assess evidence, leavened with clinician experience, and framed within the context and values of the individual patient. 

The world of medicine is quite properly focused on finding and applying the best available evidence to processes of care. Unfortunately, too often this results in the use of inappropriate hard targets and mis-applied guidelines.