Sunday, June 30, 2013

What Would Osler Say?

There is a certain feeling of disenfranchisement among those of us who were present during the infancy of healthcare social media.  Before the days of twitter, the players were few, the interactions meaningful, and the main mechanism of change was a quaint self publishing tool called a weblog. 

We were out to rule the world. Blogs were well written and lengthy.  The expectation was that the comment section would be just as lively as the post itself.  There were no book deals, TED talks, or media interviews.  We were a group of whipper-snappers, bucking the system, and blazing the trail.

The advent of twitter and facebook brought welcome improvements.  Our opinions were amplified.  Our numbers grew.  And amazingly enough, the rest of the world took notice.  We were no longer just a group of disgruntled docs.  Patients, advocates, and allied healthcare professionals also joined our ranks. 

The winds of change, however, are indifferent to mourning for the past.  Our sacred space became cluttered not only with content, but also self promotion.  Blogs became shorter and to the point.  Comments were slung at each other in small word size tidbits that often lost the subtlety of artful communication.  The noise became at times unbearable. 

We see this same type of change happening in the practice of clinical medicine.  We use terms like "creative destruction" and "disruptive innovation" to describe what medical futurists must see as the brave new world of healthcare delivery.  But I fear that we run the risk of throwing the baby out with the bath water.  In other words, quantified self, big data, accountable care organizations, and the electronic revolution must seek to add and not replace our current infrastructure. 

In both medicine and social media, it would be complete and utter foolishness to actually destroy that which was built with the blood and sweat of our forebearers.

I would like to think that today's healthcare social media giants climbed on our backs not to push us down, but rather to reach better more lucid heights. 

I'm sure if Osler was around today, he would say much the same thing.

Thursday, June 27, 2013

Life's Complications

I was preoccupied.  My mind leaped between worrying about the success of my new practice and the deathly ill young man in the ICU.  I still hadn't gotten to that blog post I had been meaning to write. I was so far into the clouds that I barely noticed them rumble.  The helmeted kids were ahead of us on their bikes, pedaling away.  My wife and I had just rounded the corner of our leisurely walk.  We were making the trip back home.

The crash above us was getting closer.  My wife turned toward the menacing clouds on the horizon, and then shouted in the direction of the kids.


I instinctively put my hand to my pocket to protect the mobile phone and sprinted forward.  As if on cue, the first rain drop plopped on my prematurely balding scalp.  The avalanche of water came quickly.  We ran past the kids who were giggling and pumping their legs for maximal speed.  My shirt clung to my chest, waterlogged.

The torrent engulfed us.  The tension between my shoulders began to relax, and all the muscles of my body gave a collective sigh.  I raised my head to the sky and opened my mouth.  We were almost home. 

We crashed through the door and crumpled to the ground.  And laughed.  And laughed, and laughed.

Husband and wife, son and daughter. 

Through the tangled stress of my complicated life, the world brought me back to silly, old fashioned, often forgotten,


Saturday, June 22, 2013

Nothing Has Changed, Everything Has Changed

It was both monumental and banal at the same time.

I sat at the restaurant with the check stowed safely in my right pant pocket.  The flimsy piece of paper burned through the cloth and singed the hair on my thigh.  It was screaming for attention,  trying to distract from the conversation and deliver me back to the worried thoughts that filled my mind over the last few weeks.  Will they come, will they come?

After breakfast, the whole family got back into the car and drove towards the bank.  They waited in the parking lot as I leaped towards the front door.  I had already filled out the deposit slip.  The line for the teller was short.  I handed the check and the slip forward and waited for something to happen.  Would thunder crash through the sky and lightning blaze down past the roof and strike me on the spot?  With little fanfare, she handed me a receipt, and I was returning to the car.

Nothing has changed, everything has changed.

With the deposit of my first check, I have started the true transition into my new practice.  Some may call it concierge, others membership based.  But what the lawyers tell me is that I am now charging for uncovered services.  There is much uncertainty.  Only after hearing my colleagues reactions have I started to question myself.  They hem and haw as they tell me that I am bold.  They envy my willingness to take such a risk.

For me, however, the risk is in staying the same.  The risk is abandoning one's beliefs to join the great healthcare race to assimilation.  Physicians will change their ways.  The art of medicine will become a borg like delivery of cookbook solutions spoken in hushed tones and explained in reams of computer printouts. 

Did you get the after visit summary, what about the patient education materials?

Will they come or not?  I have no idea. 

I am scared.  I have placed a value on my abilities, and now must wait to see if my patients are in agreement. 

What I don't question is the certainty of the stand I am taking.  Today, I stepped out of the system.  I abandoned the structure that has been placed on me since the day I accepted the position in my medical school class.

This has not been easy and comes with a great deal of risk . 

I will do it anyway.

I have done it already.

Tuesday, June 18, 2013

Demand Apathy

Monday afternoons are always the same.  I pick up the kids from their grandparents.  We drive home with their backpacks and a carton of home made food.  We park in the garage, and carry all the contents of the car into the house.  As the kids unload, I push the recycle container to the front for street pickup the next day. 

Occasionally, I stop and socialize.  Yesterday, I waited at the edge of the sidewalk as a neighbor approached.  A young healthy fellow, I was surprised to see his posture stooped and his head bent forward.  Apparently he was under the weather.  He had a slew of symptoms: fevers, chills, and a sore back. 

I enquired about his recent doctors visit.  His physician was top rate, I had suggested him myself.  But that's when my neighbor's face became particularly animated.  His visit  the week before had ended in blood tests and an Xray.  But seven days later, no results.  In fact, several calls over the last forty eight hours had been left unanswered. 

I shook my head, and watched him stumble into his house.  I knew his doctor to be of high quality, but ever since he had been bought by the local hospital, the number of complaints had risen.  It was a common issue.  A few patients each week were showing up at my doorstep because they felt like the practice they had been going to for years no longer cared for them. 

I would like to believe that this was only happening in the big medical groups, but I have heard the same among private practices also.  And sadly, I feel fairly certain that I know why.

In the old world, physicians answered only to one master: the patient.  In the new world order, patients are becoming a lowly voice in the crowd of entities shouting at physicians.  There is a kind of demand apathy.  After tending to the insurance companies, the government, the hospital, the medical group administrators, and the electronic medical record, your physician may or may not have time to address your needs.

We talk of the devastation of physician suicide.  We lament as more and more doctors bow out of clinical practice.  But on a larger scale, what may be most harmful to the American populace is the great apathy that is sprouting in this once proud profession.

My neighbor will eventually get better.  The virus attacking his system will abate.  The inflammation will resolve.

His trust in the system, however, has suffered a mortal blow.

Saturday, June 15, 2013

Invisible Consequences, The Fall Of The Clinician/Teacher

It was just like every other email I had gotten in the past.  A young student at a local university was interested in primary care, and wanted to shadow me for a month between his second and third years.  I responded swiftly.  I was delighted to bolster the interest in my speciality.  Over the years I had helped train students, residents, nurses, and nurse practitioners.  By exposing them to the office, hospital, nursing home, and hospice and palliative care, I felt I gave them a window into a nontraditional view of Internal Medicine.

He showed up on a Friday for clinic.  His excitement was palpable.  He jumped out of his seat, and trailed behind me from room to room.  But something was off that afternoon.  The patients were elderly and difficult.  Their problems were amorphous and complex.  I could see the fatigue and consternation after each visit, though he said little.

This is not how a student glamorizes the specialty when daydreaming about their future.  Eventually those that learn from me, however, realize this is a small part of the job.  They also experience the thrill of the diagnostic process, the humility of human interaction, and the privilege of becoming a part of your patients lives.

The student's gaze seemed especially trained on me when I was being distracted: the cell phone call from a nursing home in the middle of a visit, or the unending overhead pages pulling me away from what I was doing.  Time and again, though, his eyes glazed over most when I was typing on the computer.  The strain of meaningful use had altered my most intimate interactions.  As my patients were bemoaning their newest symptoms, I was busy clicking, making sure to print the after visit summary and patient education.

Meaningful use has been the tipping point, the beginning of the avalanche.  I was able to keep it together before.  Now, I have become a befuddled, frazzled, ball of stress instead of cool and in control. And this student saw right through me.

It's not that I don't enjoy teaching.  I encourage any who want to spend some time in my office.  But the number of emails has decreased dramatically. 

And like this student, those who do show up once, often decline to return again.

Tuesday, June 11, 2013

Content Is The First Principal

I think we suffer from medium confusion. 

Twitter, Facebook, and blogs are just a medium.  They are not an end unto themselves but more a mere tool or amplifier.  Our digital footprint may be littered with pictures and pithy tweets, but what separates a key opinion leader from a follower is content.

Content is the first principal.  It is where intelligence, meets communication, and dances with relevance.  Content is the work product of our brilliance.  Without it, creation dies and curation flops about like a fish out of water.

In the new world order, communication relies on content amplified by medium to be curated, aggregated, and most importantly commented on.  Content begets content, tweet begets retweet, blog post begets civil discourse through dissenting blog post.

When we create and amplify garbage, we dilute the medium.  And here's the rub, the content by key opinion leaders becomes lost in a sea of excrement. The true content producer has but two options in this great arms race towards relevance, amplify louder or increase output.  Both of which ultimately lead to burnout.

And then the true drivers of change like Mike Sevilla bow out.  We've been all yelling so loud that our faces have turned blue.  We have one up'd ourselves into TED talks and book deals.  The stakes get greater, the amplifiers are turned up higher.

Instead of killing innovation, we need to embrace it.  We have created a social media behemoth.

The future of this important endeavor lies in better filters.

We need to learn to use them more liberally!

Saturday, June 8, 2013

Is Social Media A Kingmaker? @drmikesevilla Take A Bow!

It's hard to believe that just seven hours earlier I had been watching Sting belt out Roxanne at Ravinia.  Relegated to lawn seats, I craned my neck around the entrance of the pavilion to catch a glimpse.  The large screens on either side of the stage reflected a solitary figure with guitar in hand.  He was in complete control.  The words came out almost effortlessly, but the sound and quality was unmistakable.  The crowd swayed back and forth, jumping up and down.  Thousands of hands raised, and voices sang along.  After all these years, he was still at the very top. 

This morning I crawled into the car at five AM to make the lonely trip to the hospital.  As I turned off my block and onto a larger street, I was again struck by a solitary figure.  He had a backpack, shorts, and a large brimmed hat.  He walked in the middle of the empty street, and as I passed I caught a glimpse of his face.  He was staring toward the sunrise with his hat in his hand, and a satisfied smile on his lips.


The healthcare social media community was stunned to find this week that one of our most respected and stalwart leaders has decided to sign off.  @drmikesevilla has made the personal decision to withdraw from social media.  In a series of raw posts on his blog this week, he enumerates the uncertainty and frustration many of us have felt over the years.  It does not serve to reiterate.  You can read his posts here

I feel a real connection to Mike Sevilla.  We started blogging at the exact same time in 2006.  I read some of his very first blog posts and he mine.  For years now, I have watched in envy and joy to see his meteoric rise.  In many ways, I often felt that my social media destiny was more akin to the lone journeyman on the empty road smiling quietly in the sun.  And yes, Mike was more like Sting, belting it out for crowds of adoring fans.

Only with time, have I realized that actually, we share in the fact that both of our paths have been littered with both very public and private moments.

We ask ourselves if we are relevant, we shout in the echo chamber, and then we wait for the ether to confirm or deny our deep held suspicions.

The mistake is expecting social media to be a kingmaker.

Mike, you were a king before you wrote your first blog post, and you will be one after you publish your last tweet.

Who knows the wondrous unheard melody that Sting cooed to his daughter as he rocked her to sleep.  Our lonely journeyman may enjoy the hustle and bustle of Time Square just as much as the little street I found him wandering on.

You touched us Mike, so take a bow.

We will be here when you return.  And if you don't,

That's OK too!

Wednesday, June 5, 2013

A Unified Voice

Many ask of our profession.

Are you knight or knave?

The supposition, that there exists a dichotomy of options for the current physician, is a false one.  Likely we are a little bit of both, and many shades in between.  The maddening belief that the future of our healthcare system depends on this delineation is preposterous.  I would more aptly characterize us as pawns. 

The time for change has come.

After patiently listening to my rants and raves, my readers are starting to wonder if I have any solutions for the problems I so frequently call to attention.  I have many thoughts, and a few suggestions for a path forward. 

Change, I fear, will only lead to debacle if left in the hands of politicians, economists, and administrators.  Our current state of misery stems from such loss of control.  We didn't enter this profession to care for the economy of a nation, we would much rather focus on the well being of each and every one of it's members.  Yet along with our brother and sister care providers, we are the primary driver and product of the system.  Without us, the health of this nation falls to it's knees. 

Whether knight, knave, or pawn, no soldier would enter battle without a strong suite of armour.  Yes, my fellow physicians, it's time we banded together to protect ourselves from the fall out of this massive system makeover.  This in no way changes our commitment to our patients. 

As conscientious physicians actively engaged in the care of our community, I see no way forward other then the en masse rejection of the following economically wastefull and time consuming entities:

Coding and Compliance
Meaningful Use
Face to face evaluations

By abolishing the above policies, billions of dollars of waste could be cleansed from the system.  Make billing easy and straight forward.  Each visit could be either low, moderate, or high complexity.  Submission should be in a centralized, simplified, form that should not require lavish amounts of time or billing professionals.  How much would medicare save if it didn't have to process so many million complex claims?

A universal electronic medical record that houses clinical notes, labs, and radiology is all that's necessary.  The bells and whistles add very little.  Don't make physicians slaves to big data by ensnaring them in an overly complex reporting system.

HIPAA is too complicated and costly, and needs to be converted to common sense privacy laws that aren't so dangerous and prohibitive.

I could go on, but these are a few common sense suggestions that would help the system greatly without detracting from clinical care.

Unfortunately, unless physicians learn how to use a unified voice, the likelihood for substantial change is minimal.

Monday, June 3, 2013

Picked To The Bone

My first instinct was to yell into the phone as loudly as possible.

Run away, run away while you still have time. 

But I suspected that the medical student on the the other side of the mobile would have been traumatized.  She was just trying to find an attending to shadow.  How was she supposed to know that at that exact moment the nursing home administrator had pulled out thousands of computer generated order sheets.  Each bearing my hand written signature but apparently now needed to be dated.  For ten years I had signed these documents without dating them.  But all the sudden some distant regulation had changed,  and I was on the hook.

Certainly annoying, but no big deal.  At least, no big deal unless taken in context of the rest of my day.  It started at 6AM with a phone call from the nursing home announcing a skin tear.

Sorry to wake you doc, we are following the wound care protocol, but its regulations, you know!

Then there was the discharge from the hospital.  After seeing the patient and documenting appropriately, a new litany of computer/paperwork: med-reconciliation, continuity of care form, discharge instructions, and a face to face eval.

The office was no better.  The papers on my desk had stacked up over the last twenty four hours.  I plowed through the hand written narcotic scripts, assisted living history and physical forms, duplicate death certificates, FMLA, and disability questionaires.  Of course, the power wheel chair application for my paraplegic patient was denied because I forgot to strike a pertinent negative from the review of systems.

All of this before seeing my first patient and contending with the futility of meaningful use and all those pointless clicks.

The primary care physician is being slowly picked to the bone.

Better to not say a word to the medical student. 

Let her shadow me.  The facts will speak for themselves. 

Another budding radiologist/dermatologist/allergist in the making.