Internal medicine, American health care, and especially medical education

Presenting without notes

by rcentor on October 2, 2012

Many years ago when I was a 3rd year student, my residents and attendings expected me to present patients without referring to notes.  When I became an attending, I adopted this goal.

Almost no students or residents present in 2012 without notes. 

Last night at an alumni reception, one of my former students (2006) chided me for asking her to present from memory – or as she said, memorize the presentation.

As a student, intern and resident, my job involved knowing my patients. I had to know the history, meds, physical exam and lab results.  And I could present spontaneously.

Right now, I could likely do a better job of presenting the patients I rounded on today, than the residents who admitted the patient.  And this disturbs me.

All learners and attendings should strive to KNOW their patients.  If you have to read the workup, then likely you do not really know the patient.

But then I am old school, and I guess not very tolerant.

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Wisdom and knowledge

by rcentor on September 30, 2012

We live in a different age of information in 2012.  Students and residents regularly access information during rounds, to the benefit of patients.  During my rounds, I often stop to ask someone to look up an idea.

Yet our testing still focuses on knowledge.  In reading the book Practical Wisdom, I have learned that while we can access less knowledge as we get older, we actually have more wisdom, that is that we use information more wisely.  Our judgment improves while our knowledge decreases.

I believe we have a paradox.  We judge intern applicants using knowledge based tests.  We use the same types of tests for maintenance of certification.  But judgment trumps knowledge.

Here is the problem.  Our paper-and-pencil test, our computer tests, give us information.  But a great part of wisdom is information acquisition.  How do we test history taking and physical exam skills?  How do we measure the ability to read body language, develop relationships with patients, gain their trust and therefore get the history correct?

Wisdom involves experience.  It involves illness scripts developed with great granularity.  It involves knowing when we can trust ourselves and when we need assistance.

Our students and residents understand that they can read knowledge in a book, but they need us to role model how to use knowledge and information to make excellent decisions. 

That is the problem with tests and performance measures.  Their measures are incomplete.  But the testers do not understand.  The live in Flatland while we live in a 3-dimensional land. 

We certainly need knowledge, but any experienced attending physician will tell you that knowledge alone requires experience to achieve wisdom.   Just observe the difference between interns and 3rd year residents.  The residents do slightly better on the test, but dramatically better in patient care.

Understanding the importance of wisdom is something that our leaders should address.  Our patients deserve wise physicians not just smart physicians.

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Thoughts on burnout

by rcentor on September 27, 2012

Physician a burnout has great current interest.  Many authors are worrying about burnout and therefore writing about this problem.

What are the common root causes of burnout?  Primarily burnout comes from loss of control and overwhelming undesirable activities.

Burnout occurs when the job ( becomes overwhelming.

Burnout likely is increasing because many physicians feel that they do not control their lives.  Too often the current finances of medicine "force" physicians to spend inadequate time with patients.

Administrators often encourage this behavior.  Too many administrators have examined overhead and income, and their analysis argues that physicians should spend less time with each patient.  But good physicians know that their professional responsibility requires more time with each patient.  This conflict, in my opinion, leads to burnout.

I write often that our payment system is flawed.  While I have not been this explicit before, I would argue that our payment system, especially for outpatient internists and family physicians, is a leading cause of burnout! 

Physicians are high achievers.  We want to do our best possible job.  When external forces prevent us from doing the job properly, then we have psychological distress.

Talk with a physician who leaves the "grind" and turns to retainer medicine.  These physicians are much happier with their patient interactions.

Some physicians will develop burnout in any situation.  Most of these physicians have chosen a specialty that does not fit their personality.  Obviously if the specialty does not fit the physician burnout is inevitable.

But we can and should decrease burnout through a better understand of who physicians are.  Therefore I accuse both CMS and the major insurers of a major unintended consequence.  We have too many physicians leaving or avoiding outpatient practice because they have developed burnout, or they understand that the job as currently constructed would cause burnout. 

Until we improve the working conditions for family physicians and outpatient internists we will continue to promulgate this problem.

If my diagnosis is correct, then the treatment is clear.

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Fee for service – the wrong system for physician pay

by rcentor on September 21, 2012

Bob Doherty has a very interesting and thought provoking post – FFS: What fee? What Service?

Of course, I added my 2 cents – here are some of my comments:

Yul makes an important point.  Patients want access, and not just office visit access.  A golfing buddy complained to me that he could not talk to his pulmonologist on the phone.  He said that he offered to pay for the phone all, because it was much more efficient and time saving.  But the pulmonologists practice did not have a way to accept money for a phone consultation.

The problem that I hear with FFS comes from the lack of recognition that the best care includes much time not spent in the examining room.  Our current billing system has also markedly increased overhead.

Retainer systems fix these problems for internists, and they need not be exorbitant fees.  Some models exist with panel sizes of 1000.  These cost in the range of 60-70 dollars per month.  The patient gets phone, email and text access, plus same day visits.  The physician gets enough time to spend with each patient.

The biggest problem with fee for service is the implicit message that doctors interpret.  We understand that the faster we see each patient, the more patients we can see and bill.

From a payor perspective, from a patient perspective and especially from a cost perspective this is the wrong message.  Our payment system discourages a longer visit, and leads to more consultations and testing.

We cannot just look at payment in an isolated way.  We must look at these unintended consequences. 

Most internists do believe that a PCMH or retainer type approach will allow them to provide much better care.  Perhaps we will have more internists return to doing both outpatient and inpatient care.  Of course that would decrease the number of transitions and the problems that they cause.

So we really should move from FFS to another system.  But as we design a new system, we must take human nature into account.  We must imagine how someone might "game the system", because all our experience tells us that if they can, they will.

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