Jennifer Frank, MD: A reflection on me

I recently had to readmit a patient to the hospital for pneumonia. A lovely and delightful woman, she happens to have severe COPD exacerbated by continued smoking. She knows she shouldn’t smoke. I know she shouldn’t smoke. I know that she knows that she shouldn’t smoke. We have been over this countless times.

Speaking to the pulmonologist about her care, I was informed that she needs to quit smoking. I became embarrassed that my patient was still smoking, as if I was somehow responsible for this behavior. I have been scolded by consultants on other occasions when my patient was rude to the nurse in the hospital or didn’t keep a follow up appointment. Sometimes the consultant catches herself before continuing the tirade, and sometimes my therapeutic relationship is perceived to be so close with my patient that the patient’s behavior becomes one with my own.

Really it boils down to a blow to my professional pride.
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I cringe to call a specialist on those patients who continue to abuse their own bodies, eschewing medical care until they are practically in extremis. As a primary-care physician, I pride myself on the close relationships I establish over months and years with my patients. However, sometimes my role as the family doctor seems to carry the responsibility for my patients’ actions along with it.

I liken this to what happens when one of my kids goes to school with a stain on his shirt or her hair uncombed. This doesn’t happen most mornings, but occasionally, the juice spills on the shirt at breakfast and I don’t notice the stain until dinnertime. Or, in the mad rush to get out of the house I assume my husband will brush the girls’ hair and he assumes I will and then the bus is there and the opportunity is gone. When this does happen, I wonder if the kindergarten teacher or classroom parent thinks I am careless. I am already suspect as a working mother, so maybe this adds fuel to the fire of speculation about my commitment to my family.

There is an understandable element of pride in how our children behave, appear, and are regarded. We all want to have the most beautiful, talented, polite, and exceptionally bright kids. When our children make the inevitable mistakes or fail to practice the basic elements of personal hygiene, it is challenging as a parent to not inwardly wince at what this says about us.

It is similar being a primary-care doctor. I take pride (or not) in my patients’ performance – if their A1Cs are below 7, this not only reflects what “good” patients they are, but also what a “good” doctor I am. But just like we can’t pick our kids, we can’t pick our patients. So, I must deny the pull of professional (or parental) pride and accept my patients just as I accept my own children – as imperfect people who look to me for help and often for approval as well.

Melissa Young, MD: The voice and face of my practice

Several times a day, I hear patients complain that they can’t stand the staff at other doctors’ offices:
“I like my doctor, but his staff is rude.”
“The people over there don’t know what they’re doing.”
Even some patients from my old practice tell me, “I’m so glad you left that office. I couldn’t stand so and so.”

I also hear complaints from my staff all the time that they called another doctor’s office for lab results or something and were treated very rudely:
“I don’t have time for that now.”
“[exasperated sigh] We sent that already.”
“Yeah, I’ll get to that when I have time.”
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I am incredibly pleased when patients tell me how much they like my administrative assistant and my medical assistant:
“She was so helpful.”
“She’s very sweet.”
“They are very efficient.”

When a patient calls, it’s their voice they hear first (ok, technically, they hear mine first because I’m on the phone message, but you know what I’m saying). The tone they set when they answer the phone, and the attitude they project is a reflection of the practice, and, in essence, of me.

They are also the first faces my patients see when they walk in the office. The way they are greeted and the way they are treated before they see me, sets the tone for the entire visit.

I believe it’s important for a practice to choose staff members that will portray the practice in its best light. It goes without saying that you want to hire someone competent, but you can educate people and teach them skills. It’s hard if not impossible to teach attitude and demeanor.

Googling your patients?

Have you ever Googled a patient? Should you? It’s a question physician blogger Kevin MD raises, and it seems like an interesting consideration in the ever-changing Internet/social media world.

Of course patients Google their physicians all the time. But how often do doctors research their patients online? Maybe there are some contexts in which that would make sense (Kevin MD notes that primary care might not be among them, but perhaps psychiatry.)

This issue comes as I am writing a story on how physicians can ensure the privacy of their patients while engaging online through social media networks. The whole “to friend or not to friend on Facebook” question seems to get some docs in a bind. Now this seems like an entirely new dimension to delving into the ether.

The Googling your patients question also reminds me of an inquiry I received from a reader after our Lawyer Repellant story.
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For the story, experts told me that to help avoid lawsuits, be wary of problem patients – the ones who speak ill of their previous docs or have sued before. So the reader rightfully asked, how do you know if they have sued before? (I am not sure if this is information that is easily Googled, but I do know with a little digging it’s amazing what you can find.)

I asked Medical Justice Services’ Jeffrey Segal about that, and he said (via e-mail) that there really isn’t a practical way to know if a patient has sued a physician before. Even if you could see that they have sued before, you couldn’t tell whether any lawsuit had merit or was frivolous. Compiling that information in a database would make it hard for those patients to find care. Also, I can’t imagine digging around for that information on each patient, and if the patient relationship has pushed you to that point, perhaps it’s not a good fit.

All of this is to ask how much you can and should dig around and research a patient online? Lawsuits aside, what information would you find that is relevant to treating that patient? Kevin MD notes that the overriding question should be “Will researching my patient online improve their care?”

Jennifer Frank, MD: Discipline

While swimming this morning, I entertained self-congratulatory thoughts about my dedications and discipline. I got up this morning early to go to the pool before work. Okay, in all honesty, I slept through my alarm and was awoken by my youngest one’s cry to be rescued from his crib. Because I didn’t go back to bed like I wanted to, I count this as a plus in the discipline column.

I thought further about how I am trying to follow a workout routine (parts of which I really don’t like) in order to prepare for the triathlon. I have a workout schedule that I follow pretty faithfully. Having it written down in black and white seems more inviolable than just having an idea of what I planned to do in my head. I could continue with this illustration – swimming is methodical repetition of the same thing over and over again and involves “staying in your lane” while doing it. Both of these ideas have application for parenting and being a physician.

I recently received a rather strongly worded e-mail from the Wisconsin Medical Licensing Board stating that I (and all other licensed physicians) should read the quarterly newsletter to find out about new information that applied to our licensing. I ignored the first e-mail but did take a few minutes to read it after the second e-mail arrived.
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I never found the new information but I read with morbid curiosity about all the board actions against physicians occurring over the last few months. Truly shocking and surprising in both quality and quantity. Having sex with patients, dispensing vast amounts of controlled substances to patients or yourself, gross negligence.

Reading through this newsletter of shame, I realized why professionals need to have specific guidelines (you have to wait two years after termination of the patient-physician relationship before initiating a romantic relationship with a former patient, you cannot prescribe yourself or a close family member narcotics). These both seem pretty obvious, but I think it is easy to fudge the lines slowly, gradually, and unintentionally over time, so that you are no longer “swimming in the right lane.”

Just like the difficulty in getting up super early to immerse yourself in cold water, it can be difficult to adhere to standards when a questionable case is before you or when your own “needs” seem to be so compelling.

As a parent, self-control and discipline are important as well – not only to teach to your kids, but also to demonstrate yourself. It can be so hard to be consistent when you are tired, overwhelmed, or just at the end of your rope. It often seems easier to give in to their demands than to take the more challenging role of parent – in control and the same today as yesterday.

In all my roles – as fledgling triathlete, family physician, and mom – it is essential that I not only practice self-discipline but also recognize my own natural tendencies to fudge the lines when it is convenient to do so.

What will the future of healthcare look like?

The healthcare reform debate, not to mention the rising costs and increasing demands, has forced many physicians to consider the future of their profession.

So for the April issue, we considered what the job of the private practice physician would look like in 10 or 20 years. I spoke with a host of innovative thinkers and practitioners who shared their views on how the profession would transform.

From virtual visits to more midlevels to a new reimbursement model, I heard many compelling predictions about the future of healthcare.

I invite you to check out the article and share your own notions of how the landscape will evolve.

Gerald O'Malley, DO: Secret myths and quiet truths of the ER

I was in the grocery store the other day and something caught my eye as I pushed the bananas and Ho-Hos through the price-check scanner. Reader’s Digest had an article about my childhood hero, Willie Mays (I know he was a Met, but even Yankee fans recognize greatness), but that wasn’t what made me buy the magazine.

It was the picture of the young woman dressed in scrubs accompanied by a headline like: “50 Secrets ER Doctors Won’t Tell You (Read This Before You Call 911).” I couldn’t resist.

The American ER (and the people that work in ERs) has always been fertile ground for urban myths and legends. I’ve heard the same outrageous stories told in ERs from Virginian Beach to Los Angeles: The violent PCP patient tossing around security guards after being tazed, the guy with the vibrator in his rectum, the “dead” patient that sits up and moans…

ERs all have similar stories and sometimes it gets hard to separate truth from fiction. Reader’s Digest actually picked some uncomfortable but undeniable truths to reveal as “secrets.”

Some of my favorites from the March issue of Reader’s Digest include:
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• Never, ever lie to your ER nurse. Their BS detectors are excellent and you lose all credibility when you lie.

• Standing in the doorway and staring at us while we work won’t help your loved one get treated more quickly. We’re pretty used to people trying to intimidate us.

• The busiest time starts around 6 p.m.; Mondays are the worst. We’re slowest from 3 a.m. to 9 a.m. If you have a choice, come in the early morning.

• If you come in with a bizarre or disgusting symptom, we’re going to talk about you. We won’t talk about you to people outside the ER, but doctors and nurses need to vent, just like everyone else.

Harsh to read, but I had to grudgingly admit that there was some truth to the “secrets.” The reality is that this can be a really crappy job a lot of the time. For every good, happy, positive outcome, there are a dozen that are heartbreaking and terrifying.

The first of the 50 secrets in the article seemed a little obnoxious and condescending. It read: “Denial kills people. Yes, you could be having a heart attack or a stroke, even if you’re only 39 or in good shape or a vegetarian.” Seemed a little self-evident to me.

Tonight I tried everything in my power to resuscitate a 43-year-old woman that I pulled out of the front seat of her boyfriend’s car. I remember smelling and seeing the burning cigarette in the car ashtray as I wrenched my back trying to untangle her feet from under the dash, lift her out of the car and drag her out onto the ER gurney. The boyfriend took the time to light and smoke a cigarette while he drove this dying woman to the ER.

I thought of the first secret as I sat to explain to her 13-year-old son why I couldn’t save his mother.

Melissa Young, MD: Selection bias on physician rating sites

A couple of weeks ago, a patient from my prior practice said that she Googled me to find my new location. She said that in addition to finding my new address, she also found my practice address, and an article about me that had been written while I was at my old office.

Out of curiosity, I decided to Google myself. I found the above links, but I also found links to physician rating sites. I clicked on them to see how patients were rating me. I found that almost without exception, I had either no ratings or very poor ratings.

At first glance, my one-star ratings in nearly every category make me look like a horrible physician with no bedside manner, whom no one would recommend to family or friends. I also apparently had incompetent, discourteous staff. But a closer reveals that there is only one rating. One rating by a very angry patient. One who thinks I need “to learn to be a human.”
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These ratings were all dated (where available) in the spring of last year. I can only assume that they were made by the same person. One Web site had two ratings. One with single stars across the board, dated in the spring of last year, and one with four to five stars, dated within the last three to four months.

Now, personally I don’t care if one or two disgruntled patients rate me poorly. I suspect they are noncompliant and possibly were dismissed from my practice. But other patients might care, patients who may assume that these ratings represent how most of my patients feel about me. And what happens if the payers start caring?

Who is going to take the time to go to theses sites to rate a physician? Most satisfied patients don’t feel the need to rate their physicians. Even at the best restaurants, I’m sure the kitchen hears more complaints then praise. How many store managers have customers call about an employee’s good job? And how many get calls about a bad job?

Oh sure, there are customers who will let an employer know when someone goes above and beyond, but for the most part, satisfied people don’t feel it necessary.

And the same goes for physician rating sites. I have patients I have treated for years. Some who moved out of state who still come to see me. I have new patients who used to see other docs but have chosen to see me because I have seen their neighbor, coworker, friend, or relative, and have been told that they will like me and my practice better.

Would they do that if I needed “to learn to be a human”? Referrals like that beat online ratings any day.

Jennifer Frank, MD: Consequences

Sometimes being a doctor is like being a parent. You worry about your patients, you lecture, you cajole, you warn. Sometimes your patients act like children (and sometimes your patients are children). They do what you tell them not to do (“I told you not to drink while taking the Flagyl.”). They don’t really believe you when you tell them that if they don’t get their diabetes under better control, they will be starting dialysis. They often look up to you, respect you, and see you as an authority.

As a parent, I maintain a careful balance between preventing and allowing consequences. My kids are young, so I still have this power. “If you miss the bus, you will not get dessert tonight.” Action leads to consequence. I can also intervene to prevent the consequence. “Okay, you forgot your lunch, I will drop it off at school on my way to work.” I realize that as my children get older I will be less able to protect them from the consequences of their actions. This is one of the hard parts about being a parent.

As a doctor, I have less control over consequences. My interactions with patients are, in the grand scheme of things, relatively brief. I also am paid and duty-bound to prevent consequences – I don’t allow a person to get lung cancer to prove that smoking is actually bad for you. I do everything I can to prevent lessons from being learned the hard way.
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Despite my best efforts, consequences often find my patients. The years of overeating and lack of physical activity eventually lead to diabetes. Forgoing the statin and continuing to smoke leads to a second heart attack.

During a recent discussion with one of the senior residents, she revealed the struggle she is experiencing with seeing a patient suffer the consequences of a poor choice. The resident did everything right for her young teenage patient. She counseled her on safe sexual practices, the value of delaying sexual activity since she was so young, the need for contraception and barrier protection should she make the decision to have intercourse, and the importance of being prepared for “heat of the moment” decisions.

Despite a close therapeutic bond, despite a parent who was accepting and supportive of her daughter’s decisions, despite a prescription for contraception, this young girl is pregnant. The resident did everything right but could not save her patient from the consequences.

This can be heartbreaking as a doctor (or a parent). You wonder where you went wrong, what you could have said differently, if you missed something that could have prevented this from occurring. The sad fact is that our control (as doctors and as parents) is uncertain and often almost completely absent. We have influence but little actual power. Where we do have power is in our presence – walking beside our child or patient (or friend, sibling, spouse, or parent) as they face a consequence. As a family physician, this is a role I gladly and willingly take.

Jennifer Frank, MD: My voice

I have laryngitis. This is my first bout with the sickness that takes your voice. I can squeak out a few words before I start coughing. I can whisper pretty well for several sentences before I get tired of whispering or my audience gets tired of trying to hear me. However, I am definitely unable to continue my current voice-related duties.

At home this weekend, I had to discipline without my voice. This led to two things. First, I let some things go that normally would have found me yelling either up or down the stairs to “stop chasing each other,” “brush your teeth like I told you to three times already,” or ask “is your room clean yet?”

Second, I got a lot more exercise since I had to physically locate myself in the same room as the kids if I cared enough about their current infraction to reprimand them. That tired me out quickly. So, I found it easier to just hang out wherever they were. This allowed me to watch them more closely which made it less necessary to correct them as my proximity had a disciplining effect.
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The unintended effect was that I spent more quiet time with my kids — my daughter read me a story, I taught my other daughter how to play Connect Four, I explored all of the Lego weapons my son had repurposed into even more powerful weapons, and I got some great belly laughs out of my infant son.

At work on Monday morning, I had to critically evaluate my schedule. Clinic on Monday afternoon would prove challenging for both me and my patients if I had to whisper through questions and instructions. I reviewed my appointments and was able to identify which ones needed primarily my hands or eyeballs and would allow minimal conversation. Not surprisingly, I determined that most actually needed to hear me, so they had to be rescheduled.

I couldn’t pick up the phone for the telephone conference I had planned, that would need to be rescheduled. I had a couple of important meetings to attend — both requiring at least some input from me. I considered writing down my thoughts, but was able to express everything I needed to say with a few well chosen words, thumbs up or down, and a few shakes of my head. At the conclusion of both meetings, I felt that the things that I needed to communicate had, in fact, been communicated. It is both humbling and embarrassing to consider how many more words I would have used had it been easier to do so.

Being quiet today has other benefits. When I did speak, everyone listened. They wouldn’t be able to hear me otherwise. Ironic — I usually raise my voice to be heard better. I also feel more quiet and calm. I am thinking before I speak (a rarity) because I have to save up my words to exert maximum effect. It is evident that this would be a good practice every day.

Melissa Young, MD: The weather has been frightful

My practice is in New Jersey, basically central New Jersey, although people who live closer to New York consider us South Jersey, and people who live closer to Atlantic City think we’re North Jersey. We are also fairly close to the shore. This generally makes for a mild winter with one, maybe two, snowfalls that result in an accumulation of a couple of inches. And winters have gone by when I would wonder whether my children would ever experience the joys of building a snowman or sledding down a hill.

Well, I wonder no more. We have had more snow this winter than we have had in years. Oh, we had a worse storm a few years ago, but that was it for entire winter. This year, although the storms have not been particularly bad individually, they just keep coming, and putting new snow on top of old snow.

Now, why am I writing about the weather in a Physicians Practice blog? Because these storms come in the middle of workweeks. On days when the office schedule is full. Prior to the last storm, a couple of patients called the day before to cancel. The weatherman said the snow would start in the morning but it wouldn’t be bad until the afternoon, so I said we’d stay open for the morning and close early.
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But the snow started that night, and as I looked at the accumulation starting, I decided to cancel the morning appointments, too. I didn’t want patients or my staff driving through the snow or slipping on our walkways. I was unfortunately not able to get hold of everyone, so I went in just in case people would come.

One patient came. An 85-year-old woman brought in by her 60-or-so-year-old daughter. The daughter had knocked on the rear door, generally reserved for employees only, because they had parked right outside it. When I opened the door, she went back to the car to get the patient. I cringed as I watched her slowly make her way over, carefully stepping over mounds of snow. Mind you, I had actually spoken to the daughter earlier that day, and tried desperately to discourage her from coming, but apparently this was the only day she could bring her. When I was done with her visit, I walked them to the back door again, and held my breath as they walked to the car. I stood outside the door in my white coat until I could see she was safely seated inside the car.

The day after the storm, more people cancelled, either because they hadn’t been plowed out yet, they had no one to watch the kids who had a snow day, or they were just afraid of driving through what was left of the snow on the roads.

So two days of lost productivity. Tolerable, I suppose. But guess what? We just had another storm. I think this time people have just said, “whatever,” and decided life must go on, because aside from one 85-year-old woman, everybody else showed up yesterday, and she only cancelled because her ride cancelled on her.

Now granted, yesterday the roads were passable and the parking lots plowed. Not so today. One patient had already called yesterday to cancel, and another called early this morning. So I head to the office, and I guess I was the only one insane enough to do so because the parking lot was empty. Which was just as well because it wasn’t plowed. Nor were the walkways shoveled. And quite honestly, the town had done a pretty bad job at plowing our road. So I text my staff and tell them not to come in, and I get on the phone to start canceling patients. They all said they were about to call and cancel anyway.

So aside from yet another lost day of productivity, I am also faced with the problem of where to reschedule all these people. I didn’t want to push them out a month, so I ended up squeezing them in next week during times I generally go to the hospital to do rounds or at the end of my “short day.”

So what do you do when Mother Nature doesn’t cooperate?

Gerald O'Malley, DO: Pattern recognition in the ER

ER doctors (and nurses) rely on pattern recognition to practice the type of medicine that is forced upon us when we take control of 75 patients all crammed into a space designed to hold 48 (with another 30 in the waiting room).

As Malcolm Gladwell described in his wonderful book “Blink,” good ER physicians develop reliable intuitive senses regarding the myriad ways that different diseases can present in different people and subconsciously search for patterns that guide clinical judgment. Many times, ER physicians “blink” instead of “think” (although I like to believe that we spend an awful lot of time thinking) and we learn to rely on and to trust our clinical judgment and our ability to recognize subtle patterns while caring for our patients.

What becomes really difficult to do over time, is to not bring that habit home and begin making instantaneous judgments about our spouses, our families, friends, and neighbors.
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I can recall many times that I’ve been introduced to someone outside of the ER and my first thought is, “My gosh, this guy is a tool. I bet he loves to watch grass grow, believes in global warming, and picks at mosquito bites until they bleed.” All that from a handshake and a “How do you do!” I genuinely feel sorry for any guy that my daughter brings home (I’ve got a couple of years before that becomes a serious concern) because the guy has about 11 seconds to convince me that I shouldn’t squeeze his head like a zit.

Pattern recognition is an inexact science and some are better at it than others. As a resident I used to think, “I can smell diabetes as soon as I walk in a room.” That’s not really true, I can’t “smell” diabetes, but I learned pretty quickly how to recognize the subtle clues of poorly controlled occult diabetes that might escape a non-emergency medicine trained or less astute clinician; the sticky film of sweat on the back of the neck, the two or three soft drinks consumed while waiting for me to get in the room, obesity, the general state of being unkempt and sloppy (because the constant interruptions to the daily routine caused by the disease do not allow for meticulous grooming), the thin film of greasy sheen under the eyes. There is no science behind this – these are observations that I’ve made over the course of a 15-year career in emergency medicine and caring for dozens of patients that have not yet received the diagnosis of diabetes mellitus.

During emergency medicine residency, the young physician is trained to do amazing things. One colleague told me that when he graduated residency, he believed he could sew somebody’s head back on (he has since modified his own inflated sense of his abilities). One of the most valuable things we can teach young ER physicians is to apply their intuitive ability to “blink” instead of “think” correctly, because, according to Gladwell, good clinicians are more often than not correct in their “snap judgments” which can probably lead to less testing, less time wasted, and less cost to the healthcare system. A good “blink” reflex comes in handy outside the ER when dealing with salesmen, auto mechanics, and (especially) lawyers.

What is not so easy to learn is how to turn off the “blink” and getting to know friends and acquaintances outside of the ER on a deeper level. Forming opinions of people with little or no exposure to them is not a great way to develop long-lasting and meaningful relationships.

Melissa Young, MD: The second physician

I was talking a couple of weeks ago to an internist. She had been in solo practice for a couple of years, and then she hired a former co-resident as a second physician. He left the practice after less than two years, and she has since hired a second “second physician.” I told her that I am currently in the process of finding someone for my practice.

During the course of the conversation, I couldn’t help but think back to when I was first hired at my old practice. When I was the second person. It’s a tough transition — for the new person, for the senior partner, for the staff, and for the patients. Even for new patients.

I still remember the sting of being told by patients that they had really wanted an appointment with Dr. Senior, but they couldn’t get in to see him soon enough, so they got me instead. Ouch. Well, most of them decided I wasn’t so bad after all, and actually were glad to see me in follow-up, or at least weren’t upset that they weren’t seeing their first choice.
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Well, what could I expect? My senior partner had been in practice in the community for over 12 years when I came around. All the local docs knew him. They spoke very highly of him to their patients. Who was this newcomer? Is she any good? It took years before I was recognized as my own person, someone worthy of sending patients to, someone to refer family to.

The staff had done things the same way for years. My partner’s way. He was the boss. He set the tone of the office. Sure, there were things I did my way, but it was often met with resistance. “Are you sure? Dr. Senior doesn’t do it that way.” And when we hired a third partner, he was met with the same reluctance to change things. “This is the way we do things around here; it’s how we’ve always done it.”

So when I bring a new physician on board, I plan to have new patients scheduled with her. I’m sure many of them will have been referred to me by their PCP’s, or that they will have heard about me from family and friends. Will they give my staff a hard time about scheduled with “the new doctor?” To make matters worse, she’ll be straight out of fellowship, just like I was.

I’m sure she’ll have her own unique way of doing things. Will my staff be flexible enough to handle it? Will I? Will she?

I hope for her sake that the transition will be minimally painful. I’d hate to have to look for a second “second” and start yet another transition.

What do you do to stay healthy?

Robert E. Kramer had run out of excuses for not taking his own advice to be physicially fit. So he took up running. In this month's Physician Writer Search column, Dr. Kramer tells about how he worked up to regular runs and dropped some weight:

"By 38, I proudly realized that I was a runner. I had finally accomplished what I had put off for all of those years. I was in the best shape of my life and felt truly healthy."

But, he continues, a couple years later he had fallen off the wagon and realized there is always something lurking to throw him off his running routine. He writes:

"In the end I’ve learned an important lesson. Living a healthy lifestyle, day after day, month after month, will always be a lifelong struggle. It helps me relate to my patients, who often face even greater obstacles than I do in their bid to be healthier. I keep reminding them that lifestyle change is a marathon, not a sprint."

What do you do to stay healthy?

Gerald O'Malley, DO: Violence in the ER

My job as an emergency physician is analogous to my brother’s job as a NYC police officer in that it is often defined by hours of monotony punctuated by moments of sheer terror.

We deal with the consequences of brutality every day and sudden, explosive violence is never far away. My ER is located in one of the worst neighborhoods in Philadelphia and we have very large but unarmed security guards that provide protection to hospital employees, patients, and visitors. They don’t get enough recognition.

Despite our best efforts, a determined assailant can threaten the entire ER.
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Recently, a man caved in his wife’s skull with a claw hammer because she smoked up all his crack while he was out. She suffered multiple skull fractures and brain injury, and while we were working with the trauma team to stabilize her, the assailant posed as the patient’s brother and tried to get through security into the treatment area of the ER in order to do…something. Fortunately, a Philadelphia police officer recognized him and arrested him before he made it into the trauma room.

Another guy broke his girlfriend’s neck, her jaw, her nose, and three of her ribs and while she was in the CT scanner, he checked into triage under a fake name with a complaint of an injured thumb. He sneaked out of the FastTrack, where he had been triaged and was moving through the ER going room to room and peeking through curtains looking for our trauma patient in order to do…what? One our techs noticed him, approached and challenged him, and after a few minutes of excuses, he bolted through the ambulance doors into the Philadelphia night.

We have discussed the hard economic realities of installing, maintaining, and manning metal detectors in the ER, but we all agree that a realistic cost-benefit-threat analysis concludes that it makes no sense. As a faculty, we thought that metal detectors would send the wrong message to the community we serve – that we don’t trust them or we feel threatened by them. Interestingly, a pair of surveys from 1997 (one of them conducted right here in the City of Brotherly Homicide) suggest that patients in an urban ER waiting room actually feel safer with metal detectors and do not feel that their privacy is being invaded.

I was robbed at gunpoint in high school while working the night shift at an ice cream shop. I’ve never had a gun pulled on me in the ER. Yet.

Melissa Young, MD: More on the patient portal

So just when I was about to give up on the whole patient portal thing (see last week’s blog entry), a patient decides he wants to sign up.

You know that foreign language class you took in high school, after which you could sort of carry on a slowly spoken grammatically incorrect conversation? You know how you can now recognize certain words in that language but can’t put two words together?

Well, that’s how it was for us the first time a patient actually decided to plunk down his portal registration fee and sign the authorization form. Heck, our training was three months ago! We got as far as scanning in the form. Uh, now what? Some e-mail is supposed to be automatically generated, right? And then…?
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Before we could completely figure that out, two more patients signed up. We thought we had followed all the necessary steps, but something seemed to be missing. We called a patient to find out if she received an e-mail with her username and password. No. Hmmm.

We broke out the user manual. We went through the steps again. Ah-hah! We had missed a step, a click of the mouse. We rescanned the authorizations forms and clicked away. Ah-hah (again)! Now we got a window with the patient’s username and password. We must be in business now.

I checked the administrator’s account on the portal. Yup. There were three patients on there. I sent one a message. I didn’t hear back. I sent another. Still no answer. I have no way of knowing whether the messages went through. I have not received a “read receipt.” I’m a little embarrassed to call and say, “Hey, you know that thing you paid $25 for? Is it working?”

I like having an electronic medical record. I really do. I like having minimal amounts of paper sitting around the office. I am also one who enjoys e-communication in general. I e-mail, text, IM, Facebook, chat, and (obviously) blog. I would love a secure way to communicate with my patients. And apparently, some of my patients want to e-communicate with me. I just wish there was some way to verify what goes on in the ethereality that is the Internet.

Do you ask patients to refer you to others?

Have you ever asked your patients to refer you to their friends and family? I am not talking about a small, passive sign in the waiting room that says your practice appreciates referrals. I mean, face-to-face suggesting your patient refer you to others.

For an upcoming story for the journal, I am looking into some guerrilla marketing tactics practices can use to bring more patients in the door. Stewart Gandolf, a founding partner of Healthcare Success Strategies, offered perhaps the simplest, cheapest way to market yourself - ask for referrals - yet physicians don't do it.
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As a patient, it wouldn't necessarily cross my mind to refer my physician (although, I have referred my primary-care doc to a few friends who recently moved to town or were searching for a new doc). We usually assume the docs are too busy and don't want more patients.

But if a physician says to me (ideally after I thank her and tell her how much I appreciate her), "Sara, you know, I'd like to ask you a favor. If you like what we have done for you today, I'd like to help someone else in the same way." Or something along those lines where she basically plants the seed in my head - with a tactful and rehearsed line - to refer her.

Perhaps physicians don't want to do it because they feel like they will come across as needy or sleazy, Gandolf says. Hence the need for a tactful script. And it seems like a no-brainer way to get more patients.

Gerald O'Malley, DO: I can't help you, part 3

In the ER we are frequently tasked with trying to help people that really don’t have emergency problems.

The system just isn’t designed to accommodate satisfactorily individuals with nonemergent problems, and my patients frequently become frustrated at my inability to assist them, although occasionally I have a small victory.

A patient showed up at 9:00 a.m. one day complaining of ringing in her ears for the past two months. Her primary-care doctor had made an appointment for her to see a specialist — in another three months. The high-pitched ringing was worse at night. She couldn’t sleep and was nearly suicidal. Read more
I spent 45 minutes on the phone with her insurance company and her primary-care doctor securing a referral and pleading with the specialist, and I got her an appointment at 1:00 p.m. that same day. During those 45 minutes, another six patients showed up in the ER and their care was delayed for hours while I negotiated on the phone. My patient was lucky — the specialist agreed to see her expeditiously.

As bad as things are now, I suspect that the day is coming when the specialist will just say, “I’m sorry. It is simply not worth it for me to take on this additional work and risk.” At that point it won’t matter how long I stay on the phone and no amount of pleading or bargaining or cajoling will matter. We have to savor these quiet triumphs.

Another patient wanted me to do something about the ganglion cyst on her wrist. It had been present for “a while” but had recently begun to interfere with her work, which was exotic dancing. The cyst rubbed against the pole and caused pain. She also wanted me to treat her hyperthyroidism.

“Who told you that you have hyperthyroidism?”
“Well that’s what causes you to do everything real fast, right?” she said. “Well, I talk real fast and I dance real fast too.”

She gave me a short demonstration of how quickly she can dance. The nurses loved that picture.

“So I figure that I have hyperthyroid and I need something to treat it to help me slow down.”
“Do you do a lot of cocaine?”
“Not a lot — only when I’m at work or at home.”
“I’m sorry, I can’t help you.”

How to make your patients smile

You're busy running a medical practice, so it can sometimes be hard to remember why you went into medicine - let alone spend extra energy keeping all your patients happy. But smiling patients is good for your wallet and your pscyhe. So for the February column The List, we outlined seven ways to make your patients smile. Here are a few:
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1. Be on time.
Nothing makes patients feel more frustrated than still being in your waiting room 30 minutes after their appointment time or spending 15 extra minutes waiting in a thin gown in an exam room. Feeling like you respect their time by keeping on schedule is sure to please your patients. Plus, for you and your staff, it relieves the stress of constantly apologizing to irritated patients for your lateness.

2. Enter the exam room prepared.
It is comforting for patients to feel like they are not a number, that they will be heard and cared for. That comfort is lost when you come into the exam room and have to look in the chart or laptop for the patient’s name and reason for the visit. Take that extra minute before you walk into the exam room to review the chart so you can greet the patient by name and show awareness of his symptoms.

3. Follow-up and communicate.
If your patient has had lab work or testing, was referred to a specialist, or presented with significant symptoms, make time to call her to follow up. See how she’s doing and report on any lab or test results. This helps patients feel secure that your practice is concerned about their health and didn’t forget them as soon as they left the office. Your staff can help with follow-up calls as well.

For the rest of the ways, check out the list online. And let us know in the comments here what other ways you keep patients smiling.

Trendspotter: When doctors and patients think more is better

By Ken Terry

A post on MedPage Today by my former colleague, Marianne Mattera, made me think about how much medicine has changed in the past few decades and why it costs so much more than it used to.

Back when I was in high school (long, long ago), I sprained my ankle playing basketball, and I was taken to the emergency room. After an X-ray showed that there were no broken bones, the ED doctor put a plaster cast on my ankle and recommended that I use crutches until it healed. It did heal completely in about six weeks, and I’ve never had any trouble with it since.

Mattera took her college-student son, who had also sprained his ankle, to an orthopedic surgeon on the recommendation of an ED physician. Because none of the orthopedists suggested by that doctor had an immediate opening, she went to another physician who was on the health-plan list. His office was so ragged, his receptionists so unfriendly, and his examination so cursory that when Mattera left with her son, she decided never to return. She then made an appointment with one of the doctors the ED physician had recommended. The second orthopedist had a much more patient-friendly office and seemed more competent. But, like the first one, he wanted to order an MRI.
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Why? It wasn’t because Mattera had asked for it; she said she questioned the first doctor when he suggested an MRI. Perhaps the expensive test was justified because of her son’s symptoms. Maybe the orthopedists wanted to protect themselves against liability in case surgery was indicated. Or maybe, because they’re specialists, they were hunting zebras. But whatever the reason, most sprained ankles got better on their own before MRIs were invented.

There is even some question about whether X-rays are normally required. A test known as the Ottawa Ankle Rule reliably determines whether an ankle is broken without the use of X-rays. But most doctors still order X-rays of sprained ankles to reassure patients and guard themselves against even the remote chance of a lawsuit.

When asked about the Ottawa Ankle Rule, an old country doctor whom I know was fond of telling medical students: “My radiographic dictum is, ‘It’s the patient’s ankle, but it’s my ass.’ I would rather X-ray 100 sprained ankles than go through the hassle of defending a single missed fracture in a malpractice suit.”

At least this primary-care physician, who hailed from North Carolina, treated sprained ankles. In some areas, including parts of the Northeast, primary-care physicians are not expected to handle anything that complex. If a patient has a serious condition, the assumption is that he or she will be referred to a specialist. In California and Minnesota, on the other hand, primary-care doctors tend to do much more for their patients before referring them out. The reason for those regional differences is not entirely clear, but it probably has to do with local physician cultures and business environments.

Over the past 40 years, U.S. medicine has increasingly emphasized the intervention of specialists and the use of expensive technology. In some cases, this has been a change for the better; but in other cases, doctors may be calling in the heavy artillery when a little judicious medical-decision making is called for. Unfortunately, when physicians try to do the right thing, they may find themselves being lambasted by patients who would rather leave no stone unturned and by a medical establishment that has convinced itself — and patients — that more is better.

There’s a lot of talk these days about shifting to a new reimbursement approach variously called “pay for value” or “pay for outcomes.” But until attitudes among doctors and patients change, that will be a very difficult transition to make.

Gerald O'Malley, DO: I can't help you, part 2

Some days in the ER, I just can’t seem to help anyone.

Here's the story of another patient, this one about 25 years old with chronic back pain who showed up requesting that I provide him with several different narcotics. He said he had recently moved to Philadelphia from another state and he had run out of his pain medication prescriptions.

You’d be surprised how many people show up in the ED complaining of chronic painful conditions that they had been suffering with for a long time that “suddenly run out of pain medications” and want refills. I never want to deny a patient pain medication if they are truly having pain, but my prescriptions have been forged and stolen and diverted to schoolyards. I have to be careful. My normal practice is that I require the patient to show me something to work with.
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It’s not fair to me for a patient to show up empty-handed and say: “I normally go to a doctor in New Jersey, but I lost my doctor’s phone number and I can’t remember his name but you couldn’t contact him anyway because it is 9:30 on a Saturday night and the office is closed and I don’t have any documentation of my chronic painful condition and I don’t have any empty pill bottles so can I have 120 oxycontin tablets please?” If you think I’m exaggerating, spend one Saturday night in any ER in this country and prove me wrong.

My patient today was a little more savvy than most. He showed up with a DVD containing all his X-rays and MRIs. They were all five years old, but at least he had the decency (or is it chutzpah?) to bring them with him. I contacted the last pain clinic that he had attended and, with his permission, they faxed over several pages of records including a letter from the director of the pain clinic discharging the patient from their care because he had broken the pain management contract numerous times. The receptionist at the out-of-state pain clinic told me that she gets several phone calls each week regarding this patient.

When I confronted the patient with this information, he became quite upset and defensive. He insisted that he could “barely stand up” and he needed to take several different types of narcotics, plus muscle relaxers every day in addition to an occasional percocet tablet just to enable him to do his job.

“What kind of work do you do?” I asked.
“I’m a roofer,” he said.

I called the pain center at my own hospital and they offered to see him and evaluate him in one hour. The patient declined and became testy. “I wasted two hours here, and you won’t help me at all. What did I gain from all this?”

“You got to eat lunch, watch Jerry Springer, and got a referral to the pain clinic. What more do you want? I’m sorry I can’t help you.” He muttered something under his breath and haughtily strode out of the ER.

It used to really bother me when guys like this would present themselves to my ER, but over the past 15 years, I’ve come to accept the fact that we are limited in our capacity to help certain patients because the system simply isn’t designed to accommodate their particular problem. It’s not my fault, it’s at least partially the patient’s fault, but it is primarily the fault of an increasingly inefficient system that is overburdened, overregulated, and unable to provide timely help for non-emergent but urgent problems.