Visiting the New Doctor

 

Physician tenure is usually longer than manager tenure though increasingly uncertain.  The independent practice model took its toll on me ten years ago and on my own primary doctor this summer.  He could have distributed us among the remaining independent colleagues but opted to parcel us out to the dominant medical center owned practices.  I latched onto one with some effort but completed the initial visit.

I expected to encounter a more robust enterprise.  Two old colleagues, crossed my path, one recognizing me with a hello and brief chat, the other not.  With three physicians on-site the waiting area, marked for social distancing, seemed devoid of patients.  Check-in, also marked for distance only had one other patient, a new one, also a refugee from my doctor's senior partner.  I appeared the sturdier and more independent.  His son toted his record, something I had provided the previous week, his being much bulkier than mine.

My turn came.  Height by stadiometer, weight by digital scale, blood pressure by electronic doo-dad.  All on target, though I've lost a smidgen of height from my peak, though it's never been measured with a stadiometer in the past.  Waited for the doctor and her resident to come by.  Resident didn't say a word.  As a new patient I provided a history while my new doctor checked the template circles.  Currently asymptomatic pretty much except for the planned obsolescence of chronic arthritis, and that had improved greatly from its peak severity.  Family history given.  Heart and lungs auscultated by the attending physician, not by the resident.  Usually don't find much on exam, and the younger doctors have largely lost the skill.  Neither has a lot of experience with paper medical records, commenting more about handwriting than the more important retrieval of content.  An innocuous encounter to be rescheduled for six months.

When I completed residency, that was the type of job at the top of my list.  Instead for convenience, a hospitalist position came my way as the first job out of residency.  The better choice in the long run.  Despite being on Medicare, I am an easy patient with a small list of recordable problems, preventive care up to date, and nothing medically challenging to be pondered.  I require more processing than reasoning, the most challenging decision perhaps how far into the future to schedule the next appointment.  I would bore me if my medical clones occupied that exam room all day long. 

Most surprisingly to me, the office at the centerpiece of the primary care network of the large regional center did not seem a beehive of medical activity.  Covid-19 probably limits occupancy of the office, but it's usually best when the docs on site look reasonably frazzled by not fully overwhelmed.  Maybe some folks with later appointments will challenge them more.

Pet Peeve Expression

It began with a post on Twitter from a physician inviting colleagues to relate in 140 keyboard taps or less what provokes them professionally.  His post received overwhelming responses, suggesting that a lot of physicians follow things on Twitter and really are pretty disaffected.  To bring this to a more physician focused forum, one of the editors of Medscape imported this to her forum, inviting the same question from Medscape subscribers who include a wide spectrum of health care workers.

  https://www.medscape.com/viewarticle/934411?src=WNL_infoc_200812_MSCPEDIT_DocsHate_rm&uac=1388FR&impID=2501402&faf=1

There have been about 250 responses to the invitation, including one of mine.  Some are specialty specific, some more general annoyance with the plight of health professionals.  Some wise, some with levity, some with sarcasm.  I'll offer a few of mine.

People who try to deceive me.  This includes patients whose diabetes log numbers all end in 0 or 5, who ask for far more test strips than they actually use, presumably with the intent of selling the rest to the brokers who post yellow signs on telephone poles all over West Philadelphia offering to pay for unused strips.

I intensely dislike being called a provider.  I resent the expectation of parity with others who really do not share my level of skill.  What bothers me more, maybe, is how fluently this has been incorporated into discussions by the levels of managers, from those in an alcove to those with expensive desks.  These are good people who have allowed their insight to falter.

Our Electronic Health Records and the burdens of using them are a public blight.

Measures of my performance that are really the illusions of measures of my performance.

Consults done at my invitation performed by people who know less than me without the real involvement of the expected person whose expertise exceeds mine and was therefore solicited.

Having to send somebody from my exam room who obviously needs to be admitted but is not in any distress to the ER first.

Overscheduling so that the request of the ignoramus resident that a patient seen in the hospital can return in one week when the next meaningful assessment should really be in two months when the newly prescribed medicine has a chance to do what it is supposed to do.

The fellow who brings coffee to the doctors lounge not having a substitute when he takes a day off.

Patients who have been permanent residents of the USA for decades with chronic illnesses who never thought it important enough to acquire enough local language skills to enable their doctors to do the best they can for them.

Copy and Paste as a surrogate for thoughtful analysis expressed in a medical note.

The law that requires me to pay more for a sign language interpreter out of my own funds double the  money that the office visit would bring in.

Fictional Review of Systems documented but never solicited from the patient.  The presence of dyspareunia may protect from psychosis since everyone admitted to the psych floor specifically does not have it.

Documentation of physical exam components that were really never done.

Having to obtain preauthorization from a functionary who knows less than me and cannot discuss reasonable alternatives with the threshold of knowledge needed to advocate for the patient being discussed.

Dietary solutions for people who weigh 400 pounds who really need medicine to address their problem.

Insufficient financial and talent support to go off on a tangent to explore something that catches my interest.

The hospitalist giving my longstanding office patient's consult or office followup to a colleague instead of me, and my own colleague not making the correction.

Not a bad list.  The longer I think, the longer it grows.

Step 1 Goes Generic

Assessing medical knowledge has been one of those bugaboos of medical education that has multiple purposes.  By the time a person gets to medical school, they have taken high stakes exams, from SATs, in my day College Board Achievement Tests, the Organic Chemistry final, almost certainly an MCAT once or twice.  All have numbers attached to them, designed in part to assess achievement but also to predict future potential, as these scores get submitted to others who don't really care how much math you really know but have to sort through who to select for limited entry slots.  Medical school Admission Committees skim off the success stories and regroup them into a new pool for new high stakes exams that never really end.  

The general sequence of standardized testing, not counting course examinations, includes Step 1 after the preclinical years, which for some schools tacks on the core clinical year, Step 2 during the senior year, Step 3 usually taken after internship, Board Certification after residency or fellowship, and Recertification which occurs typically at ten year intervals for most specialties.  We get pretty adept at taking them.  

Each ordeal has a number assigned to it.  The purpose of the score becomes less clear as the cohort of test takers becomes more exclusive.  Specialty certification exams, the final step, are functionally pass/fail.  Either you achieve certification or you don't, yet there is a score reported and subdivided by subject for the sole benefit of the applicant to know where some future attention to knowledge upgrades are best applied.  By Step 3, admission decisions have already been made so only a pass benefits the new physician, but the institution needs to know the caliber of those accepted into their programs and options for tweaking their curriculums.  By the time Step 2 is reported, residency match applications have been submitted.  There is a specialty score which may help the program rank its applicants but the scores benefit the medical school more than they benefit the student, especially in view of a 97% pass rate among first time takers. .

Step 1 may be the last test with serious ranking potential both for student and for school.  A recent decision to no longer report scores beyond pass/fail has created some controversy.  Good test takers feel cheated.  Program directors looking at hundreds of applicants from scores of schools liked the ease of lopping off the bottom 2/3 from further consideration.  Students whose test taking savvy fell below their grades, which are more a reflection of daily diligence, now have an advantage.  Is this a good thing?  Nobody knows yet.

In my era we had Part I of National Boards.  My school required a passing score to proceed to the clinical year.  Those who did not pass, about a dozen each year, and not necessarily those who struggled most with their courses, were assigned a remedial summer while the rest of us went to our first clinical rotation.  On repeat examination in September, our pass rate approached 100% and nobody's career was seriously impeded as much as their self-esteem was.  Scores went with our residency applications that could decide what to do with the results of preclinical years.  The biggest beneficiary was probably the school which could design its curriculum to maximize pass rates, assess the effectiveness of its pre-clinical faculty, and target students weak in a particular science for remediation in advance of the exam.  Knowing the historical pass rates also helped.  That is no more.  While in my day, we had scores that would be used later, the immediate utility was an overall Pass that punched the ticket into the clinical years.

As it goes pass/fail with no scores to be passed along either for residency screening or self-assessment, something beneficial is likely to be sacrificed.  Since the pass rates are the same as when I took them 40 years ago, there is still that element of anxiety among the test takers but it won't haunt them two years later.  They can focus on their classes.  The schools can focus on their curriculums without concern of their relative standings among schools.  But the residency program directors will need a different screening mechanism.  Likely those of the more prestigious schools will have a selection advantage that a diamond in the rough who squeaked by the competitive admissions process but thrived once on campus can no longer compensate.  Overall, I suspect people other than the program directors will eventually miss those Step 1 scores.

Transitioning Doctors

In the past year, as I've latched firmly onto Medicare, some asymptomatic numerical data has kept me more in touch with my personal physician than at any time since he served as one of my more distinguished Internal Medicine residents. He called the medicines correctly, and I've assisted him by taking them almost without fail, so numerical data obtained since the Covid-19 pandemic changed the medical care landscape has never been better. My prior quarterly assessment took place over the telephone, his taking my word for hypertensive data obtained mostly by my home kit. A second agent entered my daily pill container, the systolic BP's came down to desired levels, and I had no side effects of medication. Regional infection risks have abated enough for him to see me in the exam room.

As I waited my turn in his socially distanced waiting area, I seemed the sturdiest of the men there, no women waiting to be seen. People exited but I did not notice that none received a followup appointment, only a note from the secretary of a referral to the regional medical center.

My turn arrived, no complaints on my part. As he proceeded with the encounter, he noted that he and his partners opted to close their practice, accounting for the referral of the previous patients in lieu of followup scheduling. The reasons my doctor gave sounded very familiar, as I had done the same ten years earlier. A lease renewal with ruinous rent increase served as the terminal event. But a look around the waiting area told more. Charts, including mine, still came in bulky manila folders. He entered notes on a computer but could not afford to invest in fully electronic record keeping. Reporting data, billing, insurance, tracking hospitalizations which his group until recently had continued to follow in the hospital, and innumerable petty distractions from the more satisfying elements of being the doctor had claimed another four experienced clinicians, two late career, two mid-career . As much as I appreciated his expert guidance over many years, the time to transition had arrived.

He had inherited me from another outstanding resident who I helped train largely for geographic reasons. My office stood in the building next to his. I needed negligible medical care most of the time, some lipid management, a false alarm on a cardiac concern, allergic rhinitis before nasal steroids went OTC, and some annoying prostate symptoms with even more annoying orthostasis on the usual alpha blocker. He never seemed disappointed at tweaking the medically innocuous, unlike me who thrived on the complexity of lab work at the extremes. My blood pressure eventually needed attention and my appendix, of blessed memory, brought me to the OR after I retired, but medical care never reached complexity. An annual review with lab work became quarterly as medicine needed adjustment. I expected this to plod along indefinitely but the lure of a stable salary as part time hospitalist and part time internist for a thriving orthopedic practice replaced the burdens of independent practice management.

I had just retrieved my three month supply of medication from the pharmacy so there was no urgency to secure a replacement personal physician. As I exited the office the secretary handed me their closure letter, suggesting that followup care be arranged through the regional medical center, which had become something of a local monopoly, though a number of independent practices remained, often with concierge enrollment charges. I looked up the web site, which I expected to be the medical center's physician referral service. It was not. Rather it was an unselected list of staff physicians in Internal Medicine which numbered about 1000 individuals. Subspecialists, ICU physicians, hospitalists, education directors all aggregated with primary care physicians but excluded their whole family practice department which would add another few hundred people. The site had locations where the hospital operated satellite centers. I accessed those but none had a list of physicians assigned to those sites, let alone indication of FP or IM. Next option, called the physician referral phone number provided in my doctor's letter. I noted the site and asked her to give me a list of physicians at that site. She couldn't. This was not very helpful.

Next step, looking up a physician on their payroll who I know well, a contemporary, who I know works at one of the sites. Success. That site has seven physicians. I preferred on of the younger ones, somebody I don't know personally, and read the training bios. Interestingly, all five were women. I called the number which got answered on the 13th ring, though the person I finally reached could not have been more helpful. We reviewed the time frames for appointment, she asked when I would run out of medicine, and then we settled on a woman who seemed a contemporary of my own children who are also physicians. Mission accomplished, though I would have expected a dominant medical center to make the task of latching onto one of their employee physicians a little less troublesome than it seemed.

Contending with My FB Friends

Social media can be rather toxic, giving the full extent of humanity verbal access to you with no restraint on being abusive with no adverse consequences beyond being blocked.  Medical care also brings us into the full realm of humanity, mostly delightful people but a few for whom the most enticing response might be Undoctor.  But they rarely arrive in the hospital bed or the exam room as your perceived equal, keeping a cap on the abusiveness. But unlike patients who have no obligation to me beyond making an appointment, keeping it, and paying the fee but unchallenged acceptance provided their problem falls within my skill.  Social media is a more equal relationship but a more manageable one.  First, I am not required to show up.  Sermo has been dispatched for cause for some time.  After a few misgivings I might have been premature at not wanting to have trolls as my medical colleagues, any urge to reconnect has long since passed.  Twitter gives me access to some of the finest minds and most influential individuals around.  At that level it is not interactive at all.  At least my Congressional delegation sends a computerized thank you note when I comment on an issue, and usually my representative's position on the issue of concern to me.  Over the years, though, I've received my share of personal responses including my wording in their response.  It is really a forum for me to make a statement, though never to make a difference.  I cannot block anyone from hostility to my comments though I'm generally too much of a peasant in a forum where who you are matters more than what you think.

Facebook remains my media of choice, even to quasi-addiction in the absence of formal limitations on my frequency of access.  I know all the people designated friends personally.  I've largely stopped commenting on organizational sites where loons cannot be regulated away.  Most of my cohort comes from high school.  Ironically, few of us were close friends at the time but the exchange of comments has been respectful.  Each of us have developed over those 50 years certain proficiencies and certain predictabilites of response.  I never Unfriended anyone who I knew personally and only unfollow the occasional nudnik who posts ever ten minutes while awake or somebody who bypasses analysis to toss out a slogan.  But for the most part, my high school educated us well.

The situation with police misconduct leaves me a little at odds with my friends.  We vote the same.  We have different experiences.  My medical career has required mostly favorable interaction with constables who keep my hospital secure, officers who identify people on the street as needing medical care, prison guards who maintain a three way banter between me and the fellow handcuffed to the bed rail.  We agree that targeting Black folks for harshness is unprofessional at best, sometimes criminal or lethal at worst.  We analyze the best solution differently.  Hang the wrongdoers just doesn't change the culture.  

Medicine changed its culture in my professional lifetime.  I could not think of people more demeaning of the patient public than officers of the AMA and regional medical societies, who in many ways opposed physician accountability early in my career.  The state societies had to divest themselves of a unification requirement with a more haughty AMA just to maintain their own membership.  And we got accountability big time, but not objectionable accountability.  It came in the form of performance enhancement but without fear of reprisal which too often undermines that goal.  We have guidelines for many conditions with compliance of analyzed best practices by physicians.  Licensure requires some attention to making medical care safer through risk management.  Some of us find analysis of Big Data and institutional reporting requirements objectionable, though nobody objects to the improvement in care these efforts create.

Calls for police defunding or other punitive responses undermine public safety, not enhance it.  I already met hundreds of honorable officers as patients or in the workplace.  Some of the brutality that makes the cell phone camera exposees may very well be successful implementation of their training.  You don't fix that by any measure other than changing the training, establishing best practices, confidential peer reviews, CME appropriate to policing, and public image enhancement because you accomplished things worthy of public image enhancement.

My FB friends are probably no more outraged by events than me.  They are considerably less analytical than me and most experienced physicians in addressing it.  We've been there ourselves and succeeded but it took a generation.

New Trick for the Old Dog

My subscription to the NEJM remains in force and I schedule two articles a week, even into retirement.  Often the Case of the Week attracts me the most since it challenges my skills.  I can usually get the differential reasonably close but some of the lab testing has passed me by, even in my own specialty where I recently fumbled with a presentation of Monogenic Diabetes.  I knew the forms and the genetic identification but did not know how to correlate phenotype genetic results.  More importantly, I did not know that the tests come as a commercial panel and that it is cost effective to order it, something that I avoided doing in my Medicaid and uninsured population, asking those patients to have their affected child tested for financial reasons.

Recently, they had a case of SIADH which I recognized easily and could get a reasonable differential diagnosis.  The case included treatment with saline and desmopressin together.  I thought a rare lapse in editing, expecting tolvaptan, but later it appeared again.  So I looked it up.  Apparently the vaptans have gotten too expensive.  Since saline of the right concentration and right amount will correct hyponatremia, the barrier has been the safety of overcorrecting.  Apparently desmopressin, while counterintuitive when ADH is already excessive, provides the protection against too rapid a rise in sodium with adverse neurological demyelination.  Good to know my curiosity and inclination to challenge what seems suspicious has not been seriously impaired by retirement.

Eerily Quiet

Periodically I donate platelets, being CMV negative.  My previous donation occurred right before the coronavirus.  I delayed the followup a little, partly due to Passover which would keep me out of the post-donation snack canteen and partly because I wasn't feeling my best.  But achiness stabilized, diet resumed at baseline and I made the next donation.

Our regional donation center sits across the street from the Christiana campus of the Christiana Care Health System, the state's largest single employer.  Around the corner lies the regional megamall which predates the medical complex by quite a few years and across lies Delaware Park, a venerable racetrack with more recently added casino.  A smaller shopping center is also across the street and the main branch of the community college has a campus at the highway exit that people take to reach the medical complex.  Typically at 8AM, a lot of traffic accumulates, though not this time.  Surrounding hotels have been ordered closed by the Governor except for a few people involved in the nearby medical care.  The medical complex itself has active employees but also a lot of inactivated employees.  Retail has all but disappeared. At the racetrack, the horses need to be fed, the slot machines don't.  Our mini-metropolis looked virtually abandoned.

Inside the donor center, only modest adaptations were made.  Everyone, staff and donors, wore protective face coverings but social distancing is not realistic when nurses need to take blood pressures, measure hemoglobins, insert IV access and tend to machines.  The post-donation canteen still operated fairly normally. 

The number of donors seemed a little less than usual for an early midweek morning, maybe a little younger crowd now that these time slots are not currently prime work hours.  They are participating in an experiment to harvest post-convalescent Coronavirus plasma for transfusion to critically infected patients but it was not possible for a casual visitor to identify those donors.  Mostly business as usual, fewer people and a new video system to keep the donors from getting too disengaged while they bleed out. 

I leave my cell phone in the car during donations.  When I returned, I opened email to find a note from a friend who departed for NY a few months ago to take a job as radiologist.  I just assumed as a center of coronavirus pandemic he would be inundated with chest images to report.  He noted that it really did not play out that way.  There were coronavirus related images but not excessive.  Offsetting that was a drastic decline in other imaging as most non-urgent care has gone into hibernation.  Financially, that's a net loss for his department and a reduction in assignments for him personally. 

Coronavirus has stressed medical capacity at its peak, though more selectively than I would have imagined.  Those working can be overworked but everyone else lives amid suspended activities.