How to manage media medicine
In a prescient letter to the Wall Street Journal, Homer Jack Moore, MD, responds to a previous article bemoaning the ignorance of the medical profession about fibromuscular dysphasia:
“Your report reminds me of yet one more reason why medical care in the U.S. is so vastly expensive with little extra gain in any actual outcomes. While the implication in this article that American doctors know little or nothing about this 'common' disease is terrific for newspaper circulation, it results in terrible practice of medicine. FMD was fully reviewed in the New England Journal of Medicine in 2004 (in a report co-authored by Dr. Jeffrey W. Olin, no less), and in multiple other medical journals since then. I know what it is. So do my colleagues.
“But never mind that. I can now full well expect a flood of anxious young women (and gentlemen, too, even though FMD is even more rare in men than women) in my office, being among them those afflicted with migraines, aches and pains, anxiety neurosis, depression and other of life's ills, who have all now become convinced that the doctor is a dolt; that indeed, all life's problems would have long been solved had just that right test been done. And they will demand, now, that these tests be done, paid for with other people's money, of course. And I, knowing full well that there is no particular advantage to even the smallest particle of risk of being at the wrong end of some lawyerly deposition inquiry, will give them exactly what they demand.
“Alas, the overwhelming majority of these people will still have only what they ever had: migraines, aches and pains, anxiety neurosis, depression and other of life's ills. But in the vanishing few that, lo, do turn out to have unsuspected FMD, my advice to them, for the most part, will be exactly the same as it ever was: Take an aspirin every day.”
Ever feel like Dr. Moore does? Me too.
I think, honestly, that medical writers are better than ever in my lifetime. Often I get tipped off to relevant scientific developments by reading their columns.
But then there are the cheap-shot artists just looking to make a buck. They start with a sob story, add a dash of factoids, and then bake into an epidemic. Usually an epidemic ignored by the medical establishment; something common. After all, a malady experienced by 1 out of 10,000 patients strikes 35,000 in America every year. Pretty common, right?
There are two ways to deal with this problem, to avoid wasting time playing whack-a-mole with patient questions.
My first effort, early in my career, was to browse the contents of magazines like Ladies Home Journal and Men’s Health in an attempt to stay abreast of the breaking misinformation. That didn’t last long. There was too much trash, and it was depressing.
Then I started my own information campaign. I wrote my own practice newsletter once a year – for an example, see the dig at Dr. Gott at the end of last year’s newsletter. When I read something egregious in the local newspaper, I wrote back for publication. When the Internet revolution came along, I steered patients to reliable sites.
Before too many years had passed, my patients viewed me as the authority to be reckoned with, not the hack in the magazine. I had gotten ahead of the information curve, at least in their minds. That doesn’t stop them from asking questions, but it does stop them from questioning my answers – most of the time.
Unless writing is excruciatingly painful for you, I think you will find this useful, and maybe fun. Start with the mini-lectures you give every day. We all have them. Why not write them down? Let your personality flow through.
One of the worst pieces of advice I got in medical school was to guard my ‘professionalism’ – which meant, act like a talking robot. Balderdash. We’re all unique, and the better patients get to know us, the better they’ll sort themselves into good matches with their primary physician.
The Academy has hundreds of patient information sheets available, but they’re pretty bland. Not bad, just safe and boring. The rule seems to be “don’t say anything that stands a remote chance of being misconstrued” – like they are written by a committee. And they often advise to consult your doctor for this, check with your doctor for that – for stuff, it seems to me, ordinary commonsense people usually handle without consultation, except maybe from Grandma. If I wanted to engender dependency, I’d become a Democrat.
Frankly, when I write an information sheet it is with the intention that they won’t consult their doctor. That’s how I get an uninterrupted night’s sleep.
Posted at 06:26AM Aug 07, 2009 by Doug Iliff | Comments[3]
CAUTION! Read and follow all safety instructions
On December 3rd I listed six factors that figured into financial productivity. No. 2 was “How many problems can you manage in an hour?” This blog is about one thing you can do that will enable you to manage more problems in an hour. It doesn’t involve a behavioral, personality or intelligence change, so I know it is within reach of every family physician. Unfortunately, it runs counter to the fundamental, gut-level belief system of most docs in academic medicine, so I’m going to try to approach it delicately. Residents pay attention. This is a voice from the trenches. It won’t be news to veterans of private practice.
First, a four-item test:
Item one: This weekend I replaced 600 tiny bulbs on a long strand of greenery draping the stairs in my log home. I removed three small instruction tags from each of the strands, as well as a brochure from each box, which warns in large print, SAVE THESE INSTRUCTIONS. Unlike mattress tags, it did not warn of federal penalties for unauthorized removal.
For the first time in my life – I kid you not – I read these instructions. I now have been informed, for the first time, that I should not cover the lamps with cloth or paper. There are lots of other things I shouldn’t do, too, but I won’t bore you.
Item two: A new report notes, "the nation’s office-based system of primary care doctors is ill-equipped to deal with many health needs of adolescents, particularly issues related to behavioral and developmental issues. ... The 15-minute office visit offers little chance for probing teen concerns about their bodies and what they’re doing with them.”
Item three: I just heard during a third-quarter ad break, for the 100th time, that patients using Viagra should call their doctor if they get an erection lasting longer than four hours.
Item four: Mrs. X just became the 5,000th patient in my career to ask me for a diet.
Here’s the test: What do these four items have in common?
Here’s the answer: All of them involve a quasi-religious faith in the power of education to change behavior. In fact, there is good evidence that education can increase knowledge; some evidence, over a long period of time, that it can change attitudes; and very little evidence that it can change behavior.
There are some things that our patients really, really need to know. Those essential things can get lost in a wash of irrelevant information. The perfect is truly the enemy of the good. Maybe the good is the enemy of the mediocre.
I read the instruction manual on my chain saw cover to cover. I don’t (normally) read the instruction manual for Christmas lights or toasters or lamps. It would clutter my mind, which is already cluttered enough.
I don’t probe the minds of my adolescent patients for aberrant thought patterns. I did that, some, with my five kids, and there was never much payoff. If I sense weirdness, or if a kid wants to talk, they’ll find me open, honest and non-judgmental.
I tried to find out what to do if my patient has a four-hour erection. The PDR isn’t helpful; as best I can tell, they need an emergency operation by a urologist, or something bad will happen (gangrene?). If I ever get the call, I’d probably recommend soaking in ice water.
As a rookie FP, I printed up diet plans. No more. Now I just give a quick quiz, which I’m intending to research and publish in Annals of Family Medicine. It goes like this: Which is better for you, french fries or green beans? If they choose fries, I send them to Barnes and Noble, which has 100 linear feet devoted to diet education. If they choose beans, I send them to Weight Watchers. They need a little instruction, and a lot of accountability.
Don’t throw out the baby with the bath water, now. I’m not saying education is worthless; I’m saying you have to apply it with discretion, like antibiotics. Keep your powder dry; wait till you see the whites of their eyes; discern the teachable moment. Otherwise, save your breath, and your time.
I did an internship in psychiatry. I was the behavioral science coordinator on the faculty of a family practice residency program. I’m married to one of the best teachers in my city. I started a K-12 school in 1980 that produces National Merit finalists at ten times the national average. I edited a textbook for a two-year Great Ideas seminar. I’m not cynical about the value of education, and I’m not a virgin when it comes to the bio-psycho-social approach to family medicine – or life.
Concentrate on the bio. Trust me: You’ll address more problems, do more good, waste less time and make more money.
Now let me offer some perspective on what I have written.
1. Dr. Johnson (Samuel, not an MD) observed that men more often need to be reminded than instructed. That’s something you whippersnappers should bear in mind. When you teach, act like it is a reminder. It usually is, and it is less offensive than instruction.
2. The written word is a less threatening way to teach than the spoken word, just as the spoken word to a group (a sermon or a speech) is less threatening than a one-on-one conference. So make use of handouts, or (better yet) write your own. I give new patients a whole notebook of instructions on a variety of topics, photocopied from a dot-matrix original. It’s my way of saying that most medical truths go out of date very slowly.
3. Non-physician colleagues – whose time is less valuable from a monetary standpoint, and whose training and experience has specially equipped them – will often do a better job of depth education than I can. Agencies like Weight Watchers, diabetes learning centers or local gyms may have a miserable success rate, but it’s better than mine.
4. Last week a friend died unexpectedly, and prematurely. He was one of my long-term “knuckleheads,” an affectionate term reserved for patients who have persistently refused my attempts to systematically search for, and treat, preventable conditions. He needn’t have died. Is there something I could have said, or done, to persuade him to pay attention? That’s what haunts every veteran family physician, and it tempers my advice about wasting valuable time on face-to-face instruction.
Posted at 10:03AM Jan 05, 2009 by Doug Iliff | Comments[1]
