Friday, August 14, 2009

Am I that scary?

I have not been following the Obama health care debate very closely, but a friend of mine on Facebook posted some questions so I looked up some info about Obama's health care plan. The first link in Google points to this CNN article. The second points to this article on It refers to comments by Sarah Palin regarding "death panels."

These articles point to a couple of fears that people have: the government is going to force people to have a primary care doctor and the government is going to force people to discuss end of life care.

What's amazing to me is that being a family doc, I am a primary care doc and as a geriatrician, I regularly have discussions with patients and/or families about end of life issues. I never thought that I was so scary!

All kidding aside, I'm such a believer in both primary care and clarification of end of life issues. I can't tell you how many times I've had a patient who's primary care doctor was a cardiologist who tried to manage their depression/overactive bladder/dementia and how badly that has gone. Or how many patients have ended up getting CPR and put on a ventilator when that is not what they had wanted. The purpose of having a primary care doc and having end of life care is to make sure that every patient has someone who is responsible to knowing them and their preferences. There's no reason that should be all that scary!

Friday, August 7, 2009

I'm not ready for hospice!

This morning we had a discussion in the department about how to have the ideal hospice discussion. The author of this article was the presenter. It was an interesting thoughtful discussion based on the premise that doctors and patients often have a tough time communicating. One of the ideas that I really try to teach medical students is that the key to being a good doctor has to do with normal people skills.

The most important thing that I try to teach is that physicians don't need to know what to say, or how to have a conversation but how to listen (actively). In some ways, it is not all that different from being married. I don't need to do studies to research why my wife is angry at me, or figure out what has worked for most angry wives, I just need to ask her what's wrong and listen. Or if she's happy, what's right!

So here's my list of things doctors should do when discussing something difficult like hospice:
1. Listen, don't talk
2. When the physician is talking, the goal should be to seek further clarification of what the patient (and/or family member) was saying
3. Figure out what the patient's goals are
4. Discuss goals of care all the time, not just when the physician has a goal for the patient
5. Emphasize that the physicians goal is to help the patient carry out his/her goals.
6. If you're not sure how a patient is going to react to something, be honest about that. i.e. I'd like to bring up the issue of hospice but I'm not sure how you're going to feel about that? Or how do you feel about discussing hospice?

The goal at the end of the day is to not cram anything down a patients throat in a manipulative fashion but empower the patient by helping them maintain autonomy and control. Communication can achieve either the former or the latter. Somehow in this day and age, with all the pressures (legal, financial etc.) that doctors face, listening has become a lost art.

Thursday, August 6, 2009

Is surgery safe for older patients?

Today I saw a patient for the first time. Because of a condition, she will require bilateral hip replacements. Cardiology cleared her for surgery and ortho believes it will significantly help the patient. The surgery, however, requires 2-4 weeks of bed rest afterwards for optimal healing. And orthopedics wants to do one hip at a time. In a frail elderly patient who is bed-bound (due to her hip problem), the issue is not the surgery itself, but the recovery. This is something often missed by nongeriatricians. One number that I always remember is that an elderly person who is on bed rest for four weeks will lose 50% of their muscle mass and 75% of their strength. Joint contractures (permanent stiffness of the joints) can occur in as little as a week in an elderly patient and sometimes as little as 24 hours. Bed rest can cause a loss of calcium, and nitrogen that may never recover and new onset diabetes after 8 weeks of bed rest. In someone who is already cognitively impaired, pyschosis is not uncommon or infections such as pneumonia and urinary tract infections.

I have not met with the family yet, but a surgery requiring prolonged bed rest may still be very risky even if the surgery itself is not terribly risky. One thing to remember though is that not all people who are 85 are the same. The best predictor of outcome after a surgery is how functional a person was before the surgery. But a frail cognitively impaired older adult is going to have a very though rehabilitation course after a prolonged period of bed rest.

In other news, I may not be able to continue this blog after all. I have to clear this with the legal folks of the University of Pennsylvania. We'll see what they have to say!

Saturday, August 1, 2009

How do you pick a good doctor?

My family and I just moved to Philadelphia where I will start work on Monday at the University of Pennsylvania. My brother in law and his pregnant wife just moved here this last week as well. Between the 4 adults, 2 kids, and one kid in utero, we're looking for primary care doctors (pediatric and adult), a specialist, and an OB. We're also picking benefits such as deciding between PPO insurance vs HMO insurance (which costs at least $300/month more than an HMO insurance). So we have some decisions to make.

The funny thing to me is that the dilemma in picking a good doctor on an individual level is the same dilemma that the federal government has (and all health payers) on a large scale level: how does one determine the quality of a health care provider and whether they are worth the cost?

Most people want to know if their doctor is a "good doctor." Sometimes people mean whether the doctor knows and practices up to date medicine. The problem with that is if you could truly tell if a doctor practiced up to date medicine, then you wouldn't need that doctor. I believe that it is nearly impossible for a non physician (and very difficult even for a physician), to be able to know if a doctor practices up to date medicine.

So what else is there to go by? Here's a list
1. You click with the doctor. Never underestimate the power of a good warm relationship with a physician. The physician will think harder, listen better and care more. You will be more open, more trusting and less fearful. It's a good thing.

2. The office staff is professional. My wife and I took our newborn to a doctor once. One of the worst experiences we ever had. The office staff would unlock the front door at 9:02 for a 9:00 appt. The phones were often not answered. And they were rude. A good doctor will care about the professionalism of his office staff.

3. The doctor is accessible. The Institute on Medicine defines quality medicine as what you need, when you need it and how you need it. If you can't easily get an appointment or talk to the nurse or even the doctor, either the doctor is too busy or has an adversarial relationship with patients. Not a good idea.

4. The doctor answers questions (and is not in a rush). This is the most important for me. A good doctor shouldn't be afraid to answer questions and sometimes say, "I don't know" or "I'll get back to you later." No doctor is omniscient, should not pretend to be omniscient and should be honest. Humility is a key trait. A doctor who takes the time to draw out questions and answers them to the satisfaction of the patient will go a long ways towards building trust. They won't make things up (fellow doctors have done that to me a lot which I hate).

5. The doctor seems to take your concerns as his concerns. This goes along with the last one but makes it more personal. I hate it when a doctor blows off a patients concerns and I see doctors do it all the time. Medicine is serious. There's no room for belittling the concerns of patients and families.

6. The doctor uses an electronic medical record with a disease registry (icing on the cake). For economic reasons and tech reasons, there are plenty of docs who are great but because of a lack of finances (some EMR systems cost hundreds of thousands of dollars), some great docs don't have this. But to take medicine to the next level, you want a doc who audits themselves. This can't be done (very easily) without a disease registry. You don't a want a doc who assumes they are a good doc, but measures themselves to find out reality.

The last note is that there is no such thing as quality by association. A partner of a good doc is not necessarily a good doc. I've noticed a lot of University of Pennsylvania advertisements now that I'm in Philly and starting work there on Monday. They want people to assume that any doc at Penn is an amazing doc. I've been around long enough and in enough places to know that that is wishful thinking.

Anyway, these is not meant to be a comprehensive list, but these are some of the things I'm looking for for my family.