A Call To Those “Holier Than Thou”

First watch this:

http://www.nydailynews.com/news/national/doctors-caught-mocking-colonoscopy-patient-operation-article-1.2268965

Then read this:

There is a part of me that gets Tiffany and Solomon. I am guilty of using humor to diffuse high-stress situations. I have made jokes about patients and their ailments. I have done my share of eye-rolling when they come in claiming to know more about their disease than I do. This is a common practice in healthcare. This is how we cope. It may not be just or right, but it exists inside and outside of the world of medicine. This is not an excuse. I try my best to be mindful about letting garbage spill out.  I attempt to ask three questions before I use my voice: Is it true?  Is it kind? Is it necessary? But like all, I’m a work in progress. In addition to this, I like to ask, “If this were my aunt or my best friend, would I speak to them or about them in this way?”

I had a surgery rotation in Phoenix with a world-renown surgeon. His story was fascinating,  an immigrant who made a name and life for himself. I was in awe. Then we walked into the OR and he was horrible. He insulted and abused our unconscious patients in more grotesque ways than I can share. It took two weeks for me to report him to my clinical coordinator and for me to get out and that wasn’t soon enough.

But the vile, demeaning comments that Tiffany made are disgusting and unacceptable and go beyond anything that I could have created in my brain. And though I have an opinion about Tiffany and the leniency of her punishment, that is not what I’m here to share. She has her own path and lessons to learn. What I do feel necessary to address is about was the generalization that they made about patients. They blame patients for the ‘holier than thou’ attitude, but who are we to say what a patient knows and doesn’t know, particularly about their own body, symptoms and disease.

The internet is replete with accurate information about diseases, disorders, symptoms, side effects, everything. I often encourage patients to become ‘healthy hypochondriacs’ about their diagnoses once they get one. Patients are the experts in their own health, not us. I say this often and will stick to it. We as medical professionals, are experts of populations of people, that is what evidence based medicine is. We have no idea how each individual is going to manifest the symptoms of a disease(s) or respond to the adverse effects of a drug. When someone has diabetes, they are their own experts. They are the doctors- checking their blood sugar and make a decision on whether they will take their medications or inject their insulin, the pharmacists-deciding how much they’re going to take, nutritionists-making a choice on what they are going to eat, personal trainer- deciding on if they will exercise. Plus they have to consider their family, time, environment, work and make a decision about how that affects their health. We have a fairly easy job with chronic disease, diagnose and write medications. Then we sit on our high horse and wait. Followed by the blame game blame as the patient returns, non-compliant and sick as they were three months prior. We act as though our magic pill or ten-minute lecture would miraculously transformed their life and health.

So, Dr. Solomon, you in fact are acting ‘holier than thou’ when you speak of the Northern Virginia syndrome. Perhaps your patient had an uncle who was a GI doctor or a friend who died during a simple routine colonoscopy and he felt like he should educate and inform himself about the everything surrounding the procedure. I don’t know his story or history. But to think that you are the only one who could possibly know what goes on during any medical procedure is incredible arrogant and egotistical. People have brains and the ability to learn, just like you. My mother knows more about Alzheimer’s disease, it’s progression, signs, symptoms and treatments than my father’s neurologist and internal med doctors and she has a degree in linguistics

We have to give the power and respect back to the patient. Preventable medical errors claim the lives of 400,000 people a year, that is 1095 mistakes a day. Astounding. We’re not the gods that the world and modern culture has made us out to be. We’re human, fallible and do not know everything. Go to practice with that attitude and you can learn so much from your patients. Partner with them and help them understand the science behind the disease. Perhaps occasionally you’ll need to intervene with a few nuggets of population-based research to help guide them when they get off track.

I’m passionate about a lot of stuff. Shocking, I know. But allowing a space for patients to feel heard, respected and understood is one of my biggest points of advocacy and activism. As health care professionals, we need to use our minds and expertise when our patients are crashing or bleeding or broken. But in chronic care, I invite you to call on your heart to determine the best way to assist, educate and empower your patient.

I was called a heart-centered activist today. I’ll own that.  I work with heart and have tried to let it lead me in my 10+ years in healthcare. I will always try my best to bring awareness to what is right and just or at least as long as my community allows me to.

Thank you for reading.

Why Go To PA or NP School?

A few years ago, I interviewed the President and CEO of our local hospital system about the future of medicine. It was the first interview for my Heroes in Healthcare blog. I had a scheduled 30 minutes of his time and recorded the entire conversation on the phone via my voice recording device. Unfortunately, just like my first podcast, the audio disappeared and the few notes I had taken were lost in a move later that month.

Many of you know this doctor if you have lived or worked in Central Texas. Some have had the honor of being his patient or working along side him in the ER or clinic. He’s is incredibly skilled in the art of medicine, treats patients like his loved ones and has some of the most calming energy even in the face of emergencies. I remember one of my first days in clinic, I called him about a patient who came in with symptomatic atrial fibrillation. The paramedics were there, but they needed an order from me to treat her a. fib. I was in complete panic mode and couldn’t even begin to think of the Advanced Cardiac Life Support algorithm. After encouraging me to take a deep breath, he calmly walked me through the steps, we stabilized the patient and she went on her way with EMS. I will forever be grateful for his patience and calm through this situation and for not making me feel like a total dummy.

During our interview, we talked about how he missed his clinical practice, but felt the need to address the healthcare crisis from a different position. I also asked him where he thought medicine was headed. He told me that the frontline of medicine, the primary care providers of the future were not going to be doctors or even Physician Assistants or Nurse Practitioners, but specially trained medical assistants, community health workers, promotoras who learned about specific chronic conditions and delivered education, tools, resources and lifestyle changes outside of the clinic environment. Then if the patient needed drugs or labs or treatment, then the MD/PA/NP would take over.

I completely agree with him. I think in five to ten years, PAs and NPs will be the primary care providers and the MDs/DOs will be the specialists. This isn’t news, this has been the prevailing thought on advanced practice providers for a couple of decades now. Then in twenty to thirty years, the medical assistants, promotoras and community health workers will take over.

So why even spend your money to go to PA school or NP school? Because we’re living in today and the certification and the alphabet soup behind our name gives us credibility and legitimacy. Because in order for state medical boards and rule makers, doctors, associations to trust that we’re capable of being sources for change and responsible colleagues, we need to learn along side them in school and graduate with rigorous training. Plus it’s pretty awesome to go to PA school, especially if you’ve loved science and learning as much I have. You get to learn from leading minds in pathology, A&P, pharmacology, endocrinology, neurology and every other ology. Then you go on rotations under doctors who teach you various tricks of the trade and about the craft and art of medicine. And most importantly, you find your tribe in school. The like-minded community, your family and partners in crime, your two a.m. study buddies and competition in cartwheel contests when you need an energy boost. They make it all worth it.

Oh and your patients, they’re the main reason you should go to PA or NP school. They deserve to be treated by someone who goes into medicine for the service and not the money or prestige. We’re are the ones who are slowly shifting the paradigm away from factory medicine into a whole health model.

There are doctors who do this too, but they’re often forced into the conveyor belt of primary care and have less opportunity and time with patients. There are some trailblazing doctors who have carved a new system with direct primary care and membership-based practices. This is not to say that there aren’t amazing doctors out there, there are so many, I work with many of them. But they’re part of this broken system and often feel stuck and hopeless, I know because I talk to them often about this and that is what they tell me. To them, I applaud your commitment and persistence to the craft. I wish you for you to be empowered to take the control back from insurance companies and administrators and realize that you’re a scarce resource and actually have the biggest influence in helping change the system.v

So that’s my two-cents. I’m excited about the future for PA’s and NP’s. I love my profession and even though I am practicing clinical medicine less and less these days, I will always encourage folks to go the PA route. But I’m even more excited about having a community health worker or promotora at the end of each city block to attend to the needs of our increasingly chronically ill population. What do you think?

Photo from Ambro at http://www.freedigitalphotos.net/images/agree-terms.php?id=100103840

Your Patients Need You, But Not The Way You Think

After almost eight years of practice in primary care, urgent care and a hybrid practice of both, I have learned that 90% of my patients need me for knowledge, encouragement, a sounding board, empowerment, and some guidance more than they need me for drugs. I’ve worked in rural areas of Texas, inner cities and underserved communities my entire life and patients no longer need an ‘expert’ who orders labs and unnecessary imaging, who tells them what to take, how often to take it and return in three months to make sure the numbers we are chasing fall in range. Most chronic disease is pretty darn easy to treat.

Yes, I said it. Most chronic disease can be looked at in an algorithm and for me  it’s easy to simplify, synthesize and share with my patients. Chronic disease includes diabetes, high blood pressure, high cholesterol, obesity, hypothyroidism. If your patient is diagnosed with one or more of these diseases, the internet is replete with accurate information about the disease process, symptoms, signs, organs involved and how they’re damaged throughout the disease, the pharmacokinetics and side effects of each drug, what lifestyle change could help treat, manage and reverse the disease (s). They don’t really need us except to write for the proper drug or refer to a specialist for their eyes or feet. Or if they are emergent and way down the line and show up with a full blown heart attack or stroke or HHS, then we are definitely necessary.

Again, acute, life or limb-threatening, emergent cases, this is not easy. Treatment and management of most acute cases requires years of education and experience and to you experts, specialists,  life-savers  I bow to you, I applaud you, I thank you for all your hard work. Though I had a friend who had a few weeks of wilderness first response training and knew how to stabilize a pneumothorax better than I did and I just read about a doctor in Alaska who called a pediatric cardiologist to get advice on treating a patient who couldn’t be shipped out immediately, so there is that. But I digress, this is meant for the primary care setting.

If you are anything like me a few years ago, you’re thinking “this lady is crazy, medicine is hard and I worked my butt off to get where I am today and patients could never know more about their disease when they come into see me”. I would roll my eyes when my patients would try to give me information about a new drug or changing their diet and pretend to listen while thinking to myself that I had all the answers.

Sweet little Erica, no way. Yes, I was one of those ego-heads.

Not only is this way of thinking arrogant, but it is also wrong. We are ‘experts’ in populations of people with certain diseases, we’re not ‘experts’ of individual patients. We’ve studied evidence-based medicine, research and memorized the complex HPA-axis and the Na+/K+/Cl- action that happens in the loop of Henle and regurgitated them for tests, so of course we know everything. Wrong. We don’t.  This is where you have to release some of that ego in order to provide the best service and care for your patient.

Our patients need guidance and time, a open ear and a compassionate heart. They need someone to listen to their worries about working three jobs to feed their kids or panic about leaving an abusive relationship or their fear of losing their depressed and suicidal 13 year old. They need us to help them find the easiest and most affordable way to get more veggies into their diet and stop depending on convenient fast foods. Or a hero who is willing to stay after clinic and walk with patients for thirty minutes, break a sweat and build a community. They want someone who looks at them as a human being and not just a label with a disease who’s only value is in their blood and numbers on a piece of paper.

They need us to advocate for their needs and time. To empower ourselves and silence the higher-ups who demand more numbers and more revenue. Patients need a strong, confident source of unbiased medical knowledge who helps them find what is best for their unique biology, physiology, chemistry and neurology. Someone who curates a treatment plan that allows them to take baby steps towards big victories and motivates and encourages them to find their own individual way to heal. A provider who teaches self-care as healthcare and helps provide an easy first step to feeling good and optimistic about taking control of their own health.

Patients want and need a provider who assists, educates and empowers them to find the healer within. Can you do that?

photo credit by akeeris at http://www.freedigitalphotos.net/images/Healthcare_g355-Lady_Doctor_Teaching_p77330.html

You’ve Got The Power Doc/PA/NP!!

This weekend during my brilliant first podcast Heroes In Healthcare that will never be heard because of a corrupted file, I posed this question to Dr. Haji “I often tell my colleagues- doctors and APPs- that they have the power and the right to do what is best for their patient, to slow down and silence the voices of the higher-ups who demand more patients and more revenue. What advice would you give to someone who wants to disrupt the status quo and on the verge of being a hero, but is afraid to do so?” She said she loved that question and she talked about the need to go within and start practicing self-care as a way to create the energy and ability to take care of others. I wish I had her exact words, they were perfect and inspirational, as was everything she said.

This is something that I’ve been saying for years. I’ve pleaded with my supervising doctors to take control of their own healthcare system by creating a space to do what is best for the patient. Sometimes I told them to start a direct primary care practice, where they cut insurance companies out of the equation or I tell them that they can spend more time with their patient and charge a fee outside of co-payment. Then in the corporate clinical world, I tell my colleagues to take the time they feel is needed with each and every patient. If they’re there for cold that takes five minutes to see, do that, but if they’re there for anxiety or a broken heart, then sit and listen, offer a safe place for them to be vulnerable understanding the connection between the mind and body and the need for human connection.

I get it, I really do. I spent about five years of my practice running through patients like that I Love Lucy episode where she and Ethel are working in the chocolate factory and the conveyor belt starts going too fast and they start stuffing candy in their mouths, down their shirts, under their hats. This doesn’t work for anyone, even revenue, honestly. Most offices, corporate and privately owned, are in the red. But it especially doesn’t work for patients, the ones we were trained to serve, the ones who need it the most. It is also for us. I feel better when I get to really help a patient, even if it’s just to make them laugh, give them a hug or an open ear. My mood improves and I heal each time I get to do that.

The conveyor belt, factory type medicine can slow down with your insistence and intention. If one provider slows down and others follow suit, administrators will take note. Yes, it’s scary, yes your job safety is at risk, but there will always be an opportunity for you as long as you have a license. Dr. Haji said that we’re a scarce resource, as licensed medical professionals and we therefore truly have the power to change the system when administrators come at us with demands on our practice. Granted, I may have a proven system that works and makes patients feel like they’ve spent hours with me that I will share with you, but honestly it’s not rocket science. It’s back to the basics folks. I can tell you that I can spend two hours with one patient and still see plenty of patients in an 8 hour period and make them all feel like they’ve received quality care.

Let’s do this y’all. Let’s challenge the status quo and be the provider champions our patients need. Our healthcare system has to change and it’s within your power to take the first steps.