I am working on implementing a different type of scheduling in primary care. I know that is probably the most un-exciting way to begin a blog post so bear with me for a second because I think it is kind of interesting. Every other primary doc I know of is booked out for weeks. They have different backlogs of patients with half a dozen queues for patients. They have different slots for different types of visits each day, for example: two annual exams a day, one procedure slot, two same-day appointments, two medicare wellness visit slots, six follow up slots. They may be booked out for months for medicare wellness visits but their same-day slots may not even get filled. Continue reading Open access scheduling
The harm of the over-attentive doctor and the incidentaloma
I was talking with one of my former co-residents tonight, reflecting on our practices with regards to lab and imaging investigations on various patients. In residency I was probably one of the most conservative providers. I ordered only a handful of MRIs my whole residency, rarely ordered X-rays, avoided routine laboratory blood work, and rarely follow up imaging or labs on various mild abnormalities. She is in line with me, one of the least investigative providers in our residency. As interns we classically order very little imaging and labs, and often they were inappropriate if we did order them. As we get further along we learn what really truly needs investigating and are asking more questions, balancing more diseases and patient concerns and our ordering goes up. Continue reading The harm of the over-attentive doctor and the incidentaloma
My three rules for placebo
Placebo or practices that are poorly or not based in evidence is an ethically questionable practice in medicine. Is it okay to prescribe medications for patients knowing that they will have limited or no benefit? Because of this I’ve established three rules for myself with regard to placebo. To some extent they are unattainable but I’ll keep trying. Continue reading My three rules for placebo
My style in primary care
I’ve been suffering an identity crisis as a new primary care physician. I’ve had guidance with nearly every decision up until this point but now I’m on my own. I reflect back a distinct interaction with one of my attendings in residency. He is an osteopath, manipulates people’s muscles, and fascia for the bulk of his work. I was precepting a patient with him one afternoon. The patient had terrible sleep habits, drank caffeine in the evening, took naps at 5pm, watched tv in his bed, had untreated anxiety and would contemplate the next day’s plans all night. He didn’t work, didn’t exercise, had nothing to exhaust him during the day. He wanted a medication to make him sleep and instead I counseled him on sleep hygiene, a strategy to fix the problem rather than masking it with meds. My attending, disagreed with me and said I should just give him the med. Continue reading My style in primary care
When I was in high school and college, most of the activities I was doing were to obtain validation of others. I had quite an overpowering fear of death, or rather of being forgotten. I remember having this fear around my junior year of high school that one day I was going to die and no one would care. I quickly realized that theism was an easy way out of facing this angst and that was not going to be the solution for me. I needed something more tangible. For years that solution was to be greater, to have influence on the world, to be remembered. I pursued that through racing triathlons for a while. A few people noticed me and a couple people knew who I was. I was the first to cross the line at some little local races and I thought I was somebody. That was really hard. I tried so hard. Continue reading Intrinsic joy
Just a tuesday
In medical school we were taught hope. We were taught the infinite ways we could help a patient. We learned hundreds of medications, participated in surgeries, learned modalities, and were educated on counseling and rehabilitation. A notable piece missing from this education was how frequently medicine is a helpless pursuit and even more importantly, how sometimes it has no role. Continue reading Just a tuesday
What it’s like to die from covid
I had an odd interaction with a patient a few weeks ago. I was encouraging him to get the vaccine, telling him it was safe and effective. I dispelled all his fallacies claiming lack of research, rushed to the market, lack of long term data, and that as a late 40s guy he was at low risk for adverse effects or death from covid. I pointed out that he deferred to experts in his everyday life, trusted driving on a brand new bridge the day it was built (did not need any long term data there), and told him of several 40 year olds I had seen who had died or maybe wish they had died from covid. His response was that he was not scared to be dead. He said, if I am dead, I will be dead, so I won’t care. He has a young daughter. I told him his daughter would care. He said she would be alright without him. I told him it is not the being dead that is so scary, it is the dying part. He said he thought he would be sedated and unaware for that whole process. That is what baffled me the most. He had literally no idea how people die from covid. I want to dispel that. Continue reading What it’s like to die from covid
The strange ethics of vaccination, male contraception in comparison to cancer screening
We are facing a global crisis with an absurd amount of people refusing vaccination. I have nearly hourly conversations with patients about the importance of vaccination and largely my professional advice falls on deaf ears. To be honest, I’ve probably overly entertained the ethics and decision challenges regarding vaccination and find some similarities between that and male contraception in comparison to cancer screening.
Discussing specifically the medical ethics of immunization for rare diseases, it is kind of a strange practice. In the context of covid-19 vaccination this is moot given the absurd prevalence and declining the vaccine is really just an inability to make adult decisions. Nothing else. However, in the case of rare diseases, when we choose vaccination we choose to take a therapy that may potentially in even more rare circumstances cause us harm in order to protect those around us. It is an individually and medically absurd decision, but socially is absolutely vital. Continue reading The strange ethics of vaccination, male contraception in comparison to cancer screening
The sin of the rvu
I could never have fathomed how badly residency and medicine in the US could try to beat the compassion out of me. We all went into medical school with bright eyes, touting our love and desire to help people as our primary motivation for pursuing this career. It is likely what made us special, what marketed us as exceptional beyond the grades, MCAT scores, and extracurriculars. And yet a year and half into residency I am finding persistently berated by moral injury of a desire to help people in a system that seemingly strives to make it nearly impossible to do that.
A few months ago my residency transitioned all of our appointments to 30 minute slots, a subtle but heinously impactful change from a mix of 30-45 minutes appointments prior. Independent of new patient or established, routine or presenting with a dozen chronic diseases, we have 30 minutes to meet another human being, learn what makes them who they are and why they strive for health, and make recommendations to help influence their lives. The system is set up this way because of financial incentives to decrease duration of visits while maintaining revenue, a meaningless need to reach the arbitrary number of 1650 patient encounters before the end of residency, and a need to supply care for seemingly infinite demand with extremely limited supply. Continue reading The sin of the rvu
When to hold back?
Yesterday I led a case conference regarding ambiguous care for a complex patient. It was with regards a patient with shoulder pain with a small labrum tear, multiple comorbidities, severe illness anxiety who was maxed out on medical therapy, pain refractory to physical therapy and other conservative interventions. I hesitated very much on referring her to a surgeon because I knew she would likely get a surgery of questionable benefit with possibly worse outcomes. There is gross incentive for the surgeon to still perform surgery and it’s hard to refuse a patient when they likely will just go find a surgeon who will do it. I know that was the pathway and that is what happened. And then she got worse. Continue reading When to hold back?