Category: Healthcare

The Practice of Medicine is Both Art and Science

The Practice of Medicine is Both Art and Science

Learning medicine is a scientific endeavor, practicing medicine is an art.

Dr. Ricardo Rosenkranz

During my visit to the Urgent Care Center for an infected eye late last year, I was reminded that medicine is both art and science. The physician brought in the final paperwork with the instructions for discharge. As we exited the exam room and walked down the hall toward the exit, I peppered the physician with questions – Did he think my eye infection was caused by a virus? Did I have a virus? Did I, in fact, have the flu?

To all of my questions, the physician simply shrugged his shoulders, as if to say, he didn’t know. Now there are tests that could determine if my eye infection was bacterial or viral. However, results from such tests would take a few days. The doctor’s approach — treat the symptoms, watch for improvement, and if my eye got worse return for follow-up.

I was curious though and pushing for answers, wanting his perspective. The physician finally said, ‘you know, it’s all just a bunch of voodoo. There’s so much we really don’t know.’ I burst out laughing. How refreshing to hear a physician say, in so many words, that doctors don’t always have the answers.

Medicine as Science

Unfortunately, many physicians will not admit to not knowing, particularly in interactions with patients. There is an expectation, stubbornly held by both physicians and patients, that physicians are always supposed to have the answers. This is simply unrealistic. Patient harm often results when physicians fail to admit they do not know. Patients are diagnosed and treated for ailments they may not have. Communication and coordination of care often falters. And there is a general reluctance to call in specialists and experts for different perspectives or recommendations. Calling in reinforcements, in fact, may be just what is needed to achieve better outcomes. Recent research published in JAMA Network reveals higher diagnostic accuracy with a collective versus an individual approach

Medicine as Art

Acknowledging the mystery in medicine is a step in the right direction. According to Dr. Ricardo Rosenkranz², magic may serve to provide the insight, perspective, and passage to a deeper connection between physician and patient.

In December of 2016, I had the privilege to attend a magic show highlighting this relationship between magic and medicine.³ The magician was Dr. Ricardo Rosenkranz, a practicing physician and Assistant Professor in Clinical Pediatrics at the Northwestern University Feinberg School of Medicine.

The performance, as all good magic does, mystified and dazzled. But this particular magic show also highlighted –

  • the value of listening
  • the need for ritual
  • the importance of storytelling
  • and the power of empathy

— all essential ingredients not just to a great magic show but to best practices in medicine as well. Dr. Rosenkranz is committed to changing medicine . He uses his skills as a magician to first spark the imagination, with the intent to transform behavior, acknowledging both the art and science of medicine.

Creating a New Path

In addition to his performances, Dr. Rosenkranz has created a “curriculum on magic and medicine for the Medical Humanities and Bioethics Program at Northwestern targeting first and second year medical students. The intent of the program is to help medical students develop a deeper understanding of the doctor-patient relationship.” [as stated in the program]

Dr. Rosenkranz is teaching medical students how to be better doctors. In turn, Dr. Rosenkranz asks patients, as he asks his audience members, to come prepared to engage. By improving the dynamic between physician and patient, there is an opportunity to positively influence the experience, not necessarily the outcome, but the experience.

During times of serious illness, moving forward in the face of uncertainty is challenging. It is essential, however, for both physicians and patients to acknowledge medicine as an imperfect science. There might not always be answers, but it is in this acknowledgement that both physicians and patients can move forward in a healthy way. Medicine is both art and science, come prepared and stay engaged.

¹JAMA Network Open. 2019;2(3):e190096. Doi:10.1001/jamanetworkopen.2019.0096

²The Rosenkranz Mysteries, the Show, About Ricardo Rosenkranz. December 2016

³Medicine is a performance art: combining magic and medicine | Ricardo Rosenkranz | TEDxNorthwesternU. 2015

Are These Medical Tests Really Necessary?

Are These Medical Tests Really Necessary?

Have you ever stopped a doctor from ordering and performing medical tests and procedures that may be a repeat test, nice to know but not critical, or perhaps even unrelated to your issue or concern? If so, how did that go for you?

I’ve discovered I’m not good at saying ‘NO’. I worry about the consequences: Will my care get compromised? Will I get labelled as a ‘difficult’ patient? Perhaps even denied care? However, data indicates unnecessary testing only drives up costs for healthcare which are already high and out of control. Kaiser Health News estimates the costs of unnecessary medical tests and procedures at $200 Billion.¹ Such data suggests there may be value in asking questions and becoming a better advocate for my own care and treatment.

Test Now, Ask Questions Later

Two years ago, I made an appointment with a podiatrist because I was having foot pain, specifically, heel pain. Before ever seeing the doctor, the technician asked me to stand on a platform and two separate x-rays ($88 each) were taken of my foot. By the time the doctor walked into the exam room, based on my description of the pain to the technician, she was ready with a diagnosis. I had Plantar Fasciitis, a condition that occurs when the ligament, that stretches from the heel to the toe, begins to pull away from the heel and becomes inflamed.

X-rays provide images of bones, they don’t provide a view of ligaments and tendons. In some cases, Plantar Fasciitis can produce a heel spur. Heel spurs though rarely cause pain and wouldn’t change the recommended initial course of treatment. Perhaps my physician used the x-rays to ‘rule out’ other diagnoses, but I’m confident the doctor knew my diagnosis even before the first x-ray was taken. As it said in the literature sent home with me after my appointment, “Heel pain is one of the most common conditions podiatrists treat. It accounts for approximately 15 – 20% of our practice.”

Based on her years of experience, this doctor could have arrived at a diagnosis based on a conversation with me about my pain and by manipulating my foot. However, in today’s healthcare system, physicians are financially rewarded for medical tests and procedures conducted in their offices. A fee-for-service healthcare system, benefits the practice while also driving up healthcare costs. This is a horrific waste of time, money, and resources.

Wait a Minute, Why Did You Ask For My Previous Records?

More recently I accompanied my husband to the eye doctor. He was following up with a specialist due to an unusual speck in his eye discovered during a routine eye examination. When setting up the appointment, my husband was asked to have his records forwarded to the specialist’s office, which was in the same building as the original optometrist. The records were all relatively new, certainly within the past month.

However, at the specialist’s office, the technicians proceeded to conduct the same tests as the first doctor (eye charts, dilation of the eyes) rather than building on information already collected and moving directly to the tests to aid with diagnosis and recommendation. By repeating these tests, the office is able to bill insurance, which pads the monetary return to the specialist.

In the ongoing debate on the future of healthcare there’s a lot of binary discussion – ‘medicare for all’ vs. a private/public option. The main focus for these debates is on access, which is important, but access to a broken system is rather problematic. Medical testing is intrusive taking time away from patients as well as exposing patients to additional tests and procedures which in the end might not actually be necessary. It is not a harmless practice.

The Importance of Patients Asking the Questions

In her book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, Elisabeth Rosenthal outlines reasons for the high cost of healthcare. According to Rosenthal, insurance companies, hospitals, physicians, and pharmaceutical companies – all share in the blame for rising costs. As she states in the introduction: “These days our treatment follows not scientific guidelines, but the logic of commerce in an imperfect and poorly regulated market, whose big players spend more time on lobbying than defense contractors. Financial incentives to order more and do more – to default to the most expensive treatment for whatever ails you – drive much of our healthcare.”²

Much needs to be changed in the delivery of healthcare in the United States today. But, as Rosenthal asserts, the current situation demands that consumers must be active participants in their own healthcare. As patients, this would suggest we need to begin to ask questions about tests and procedures during a physician or hospital visit. Questions might include: What is the reason for this particular test/procedure? What is the cost? How does this fit with the reason for my visit?

As patients, we have an opportunity to change how medicine is currently practiced. I am more willing to ask questions knowing how critical it is for me to be an active member of my own care team. I hope this article will give you some courage as well. Let me know how it goes.

¹https://www.healthcarefinancenews.com/news/unnecessary-medical-tests-treatments-cost-200-billion-annually-cause-harm

&sup2Elisabeth Rosenthal, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (New York: Penguin Books, 2018), p. 5

Does Direct Primary Care Offer a Better Alternative?

Does Direct Primary Care Offer a Better Alternative?

The healthcare system in the United States today misfires on communication and fails to coordinate patient care. In the current system there is little patience for listening to and caring for the whole person. And physicians are burning out. Doctors are forced to spend more time and effort on paperwork navigating systems than actual patient care. The two participants that matter most, the very reason for healthcare — the physician and the patient — have lost control. Does Direct Primary Care offer a better alternative?

What is Direct Primary Care (DPC)?

Direct Primary Care provides patients with access to a primary care physician for a monthly fee. This fee is paid directly to the physician rather than paying for healthcare through an insurance premium. Monthly fees average $77.38 depending on the range of services offered or the location of the practice.

In some DPC practices, lab tests and pharmaceuticals are available at a discounted rate. DPC is not insurance. In order to cover major medical expenses and hospitalizations, patients are encouraged to carry high deductible insurance.

DPC practices have fewer patients than traditional primary care practices. With fewer patients, physicians spend more time with patients during each visit. In theory, more time allows for deeper discussions. Physicians gain insights needed to assist with diagnosis. Additionally, physicians may uncover potential barriers in a patient’s ability to follow through with treatment recommendations.

The intent of DPC is to help realize the benefits of preventative care. Identifying health concerns earlier prevents the escalation of issues that lead to poorer medical outcomes and increased hospitalizations.

Benefits to Patients
From a patient perspective there are many attractive elements of DPC.

  • More time with a physician which increases the odds of feeling listened to, establishing trust that improves quality of care.
  • Greater continuity of care improving communication, understanding, and decreases in medical errors.
  • A focus on the whole person rather than compartmentalization and defining a person by a diagnosis.
  • Guaranteed access to care through a comparatively low monthly fee. For patients with chronic conditions like hypertension, asthma, and diabetes there is comfort in having guaranteed access to care³.
  • Controlling costs with the monthly fee rather than paying high insurance premiums per visit.

In the end, patients are paying the person providing care rather than lining the pockets of organizations that have hijacked the practice of medicine – insurance companies and pharmacy benefit managers.

Benefits to Physicians
Physicians attracted to the DPC model see it as an opportunity to reclaim the practice of medicine. Costs are transparent. In this model, medical care is not limited by billing restrictions and fee-for-service incentives. Furthermore, DPC provides a viable alternative to physicians that might otherwise exit the system due to burnout.

Potential Concerns
At this time, there are no comparative studies and performance statistics on DPC versus traditional models of Primary Care. Concerns about DPC include:

  • The potential cost burden for patients that pay both a monthly retainer and insurance premiums for high deductible coverage
  • Laws that restrict the usage of insurance premiums to cover the retainer fees
  • More pressure on a system with a shortage of primary care physicians.

DPC as an Opportunity to Begin Change

As costs for insurance premiums continue to rise, DPC may be an affordable option for patients that might otherwise not have any coverage. Current models of healthcare are already failing physicians. Burned out physicians are leaving the system either through early retirement, exiting for other lines of work, or by suicide (U.S. physician suicides are twice the national average.)

There is a need for change. While DPC may not be a perfect model, it may very well be a viable alternative at the present moment. Today, insurance companies and pharmacy benefit managers control the practice of medicine. Physicians and patients need to regain control. The practice of patient care belongs in the hands of physicians and patients, and in their hands only.


¹Cole, E.S., (July 2018) Direct Primary Care: Applying Theory to Potential Changes in Delivery and Outcomes. The Journal of the American Board of Family Medicine, 31 (4) 605-611.

²Huff, C., (October 3, 2017) Flat-Fee Primary Care Helps Fill Niche for Texas’ Uninsured. Kaiser Health News.

³Andrew, L.B., MD, JD. D

Finding a Doctor After a Move

Finding a Doctor After a Move

Just over a year ago my husband, Tom, and I arrived in the Pacific Northwest after many years of living in various places throughout the Midwest. We were in search of better weather – relief from icy cold winters and hot humid summers.

Besides weather, two other major considerations for relocating – to be out west and in a college town. One significant factor we didn’t consider — healthcare.

I don’t believe we were completely negligent. We knew there was a hospital given we had visited with our son on Thanksgiving Day just the year prior to our move. The hospital was clean, the ER care efficient, and billing wasn’t a hassle.

Additionally, we asked a friend who had grown up in this particular place about the quality of healthcare; there weren’t any negatives or red flags. Our insurance provider even provided us with a list of recommended physicians that accepted our insurance plan.

Active Participants in Healthcare

I never suspected that finding a physician would become the major stumbling block to establishing healthcare. The vast majority of physicians in this city are aligned with either one of two physician groups (one of the groups is affiliated with the hospital.)

Tom and I take care of our health by exercising regularly and eating a well-balanced diet. Despite our best efforts though we both have chronic medical conditions. For Tom it’s managing high cholesterol and for me it’s Multiple Sclerosis. Therefore, we expect our healthcare providers to have the expertise to manage such medical conditions.

As senior citizens, we also desire healthcare providers with both the knowledge and the experience on medical changes that occur with aging – bone health, metabolism, and cardiovascular issues.

We consider the relationship between a provider and patient a partnership. In our experience, the practice of healthcare improves when there is good communication and trust, factors dependent on the continuity of care. Such care begins by establishing a health baseline; such a baseline provides context for whether or not any changes should be a concern.

Difficulties With Finding a Physician

Tom was the first to begin the physician search and ran into obstacles immediately. The physician group not directly related to the hospital would not accept new patients with Medicare. And the hospital affiliated physician group wouldn’t let Tom choose a physician from the list of physicians recommended by our insurance plan.

In fact, the physician group selected his provider, a D.O. (Doctor of Osteopathic Medicine). My husband did not have a choice. There was no opportunity for him to select a physician based on patient recommendations, physician specialty, experience, or compatibility. After one year, Tom’s physician moved into a new role. So much for continuity and having a baseline. Tom now begins again, this time with a newly assigned Nurse Practitioner as his primary care provider.

More Difficulties with Finding a Physician

My experience with finding a physician presented slightly different challenges. I was determined to select a primary care physician based on my criteria – Internal Medicine and female – from the list provided by our insurance company.

After a few phone calls, it became clear I could not make an appointment directly with any of the physicians in the group affiliated with the hospital. It was mandatory to use their Find a Doctor phone system. And apparently the only primary care providers available to me as a new patient were either D.O.’s or Nurse Practitioners.

I finally found a physician from the physician group not affiliated with the hospital. The receptionist on the phone though wasn’t sure whether this physician was accepting new patients. I had to wait several days for a return phone call. Fortunately, this physician was accepting new patients, however, the next available appointment was not for another NINE months. I said I would wait.

My first appointment was informational only – no annual exam. When the appointment finally happened, I discovered the reason for the long wait — she only works part-time. I did mention our difficulties with finding a provider and she informed me there is a shortage of primary care physicians. Our small city not only has challenges with getting primary care physicians to locate here but struggles to keep them once they arrive.

A Primary Care Physician Shortage and the Impact on Quality of Care

The national news has certainly covered the lack of primary care physicians and how this issue is only going to deepen given fewer medical students choosing primary care as a profession. But I would have thought a city in the Pacific Northwest with a high quality of living, that such a place would be desirable for new physicians to locate, and particularly new physicians with families.

The whole process of finding a primary care doctor has been a bit of a culture shock for both of us. I’ve had to wait for physician appointments before but I’ve never had ACCESS to a physician controlled by a physician group. And as my husband said to me recently, he has no CONTROL over his own healthcare. He is beholden to whatever may be the strengths or weaknesses of the provider selected for him.

This does not feel like patient-centered healthcare. And as senior citizens, we feel particularly vulnerable. This is a time in our lives when continuity seems vitally important, when relationships with providers that we know and trust is preferred, and good communication is essential.

What are Your Experiences?

So, I am curious about your relationships with medical care professionals. More specifically, have you experienced any issues due to the national shortage of primary care physicians?

What Are Hospitalists and Why Should You Care?

What Are Hospitalists and Why Should You Care?

Jim first encountered hospitalists during his stay for necrotizing (flesh-eating) pneumonia. Over the years, Jim’s experiences with hospitals have been many including cardiac by-pass surgery and a hip replacement. Both Jim and his wife Gwen, however, describe their recent experience with hospitalists as unsettling. When Jim was admitted into the hospital, his primary care physician could not help manage his care. The hospital had their own doctors.

What are Hospitalists?

Hospitalists, as defined by the Society of Hospital Medicine are: “Physicians whose primary professional focus is the general medical care of hospitalized patients.”¹ The presence of hospitalists in U.S. hospitals has increased dramatically in a relatively short time frame. In 2014, the Society of Hospital Medicine estimated more than 44,000 hospitalists worked in U.S. hospitals, a significant increase from the estimate of 14,000 only ten years earlier.² Reasoning behind the implementation of hospitalists:
  • Physicians dedicated to hospitals will know hospital procedures. Such familiarity suggests greater efficiency and effectiveness when ordering tests, prescribing meds, and handling paperwork.
  • Hospitalists know the clinical staff. Knowing clinical staff should facilitate coordination of different specialists, or forming a care team, depending on patients’ needs.
  • A hospitalist provides a single point of contact (SPOC) for patients, families, and caretakers. A SPOC should improve communication and understanding of tests and procedures.
Bottom line, hospitals are embracing this role with the intent to improve both efficiencies and the quality of care within the hospital.

Jim's Experience

As a patient however, Jim is now dealing with a physician that doesn’t know him. A physician who doesn’t have experience with his medical history. Quite simply, the hospitalist doesn’t know what normal looks like. As Gwen put it, “the hospitalist doesn’t know that Jim’s face is very red all the time and that his face should be all red, maybe. And that when he came, if he was green, maybe your own doctor would know ‘Oh, he’s always green, he’s always blue.’”

Primary care physicians have both history with a patient and they know what is normal. Jim and Gwen experienced a lack of continuity in the delivery of care, during a dramatic health scare, a time when continuity matters.

So What are the Statistics on Hospitalists?

Recent studies have examined the role of hospitalists in both patient outcomes as well as in the transition of care when patients are discharged.

  • In a study published in December 2017, the Journal of the American Medical Association concludes that “patients cared for during a hospitalization by their own primary care physicians had slightly longer lengths of stay, were more likely to be discharged to home, and were less likely to die within 30 days compared with those cared for by hospitalists.”³ These findings would suggest that familiarity does have an important role in patient outcomes.
  • Another study, funded by Patient-Centered Outcomes Research Institute (PCORI) and published in the Annals of Family Medicine, examined care transitions from the perspective of patients and caregivers. The lead author on the study, Suzanne Mitchell, commenting on the findings during an interview with AAFP News said, “The real punchline is that despite millions, if not billions, of dollars of investment to improve care transitions in hospital discharges, from the patient and caregivers’ perspective, everything still looks the same.”

Taking Charge of Your Hospital Experience

Hospital stays are often stressful; there is a lot happening that can be new and confusing. And the trend toward hospitalists is still on the upswing. As frustrating as it may feel, it is necessary for both patients and caretakers to take a more proactive approach regarding their care during a hospital stay and during discharge.

During the Hospital Stay

  • Share all of your prescription medications as well as over the counter supplements with hospital personnel. Ensure that this information becomes part of your medical record in the hospital. Consider creating a list now. Keep it updated periodically and have it handy when needed. Such a list is important not just for a hospital stay but also for physician appointments outside of the hospital.
  • Clarify whether or not the hospital utilizes hospitalists. If so, make sure to get to know this person. During a hospital stay, many hospital personnel rotate in and out of the hospital room. If a hospitalist should introduce him/herself, the introduction may get lost, or a term other than hospitalist is used. Make sure to know who the hospitalist is and ask this person to clarify his/her role, and share what to expect, going forward.
  • Hospitalists work odd shifts – sometimes 7 days on and 7 days off. Find out the schedule so that you can be prepared if there is a change. Ask for a clarification of the hand-off procedure between hospitalists (does it happen in-person, through notes in the medical chart, e-mails, etc…)
  • Confirm the hospitalist has been in touch with your primary care physician (if you have one) regarding your hospitalization and your diagnosis.
  • Verify that other clinical personnel and specialists in the hospital are aware of the treatment plan and directions from the hospitalist. Ensure that everyone has the same understanding regarding medications and next steps.

Before/During Discharge

  • Determine whether or not your hospitalist has consulted at any point with your primary care physician during your hospital stay. If so, identify what was communicated.
  • Ensure there is a discharge plan for your release from the hospital. Make sure this plan is reviewed with you before you leave. Take the time to understand the discharge plan and ask any questions you may have regarding the plan. If there are concerns about safety, or what to expect when you get home, be sure to share these as well.
  • Review the medications that are prescribed for you as part of your discharge. If there is a change in the list from when you went into the hospital, make sure you know the reasons for the change.
  • Check to see if you have been provided with a number to call should you have any questions or concerns after you are discharged. If a number was not provided, ask for a number. Also ask for a number that is good 7 days a week, 24 hours a day, if you should need emergency assistance.
  • Determine whether or not your primary care physician will be notified of your discharge. Ask when the primary care physician will receive the discharge summary from the hospital (typically it should arrive within two weeks, if not sooner.) Information to be included in a discharge summary: diagnoses, abnormal physical findings, important test results, discharge medications, follow-up arrangements made and appointments that still need to be made, counseling provided to the patient and family, and tests still pending at discharge. Request a copy of the discharge summary be sent to you as well.

Why Does It Matter?

These are just a few steps to take during a hospital stay to ensure safety and optimize care. Again, the hospitalist does not know what normal looks like. It’s important to share, if like Jim, your face is normally red. Or perhaps for you, normal is green or maybe even blue. For more information on improving communication between physicians and patients, check out this post on what happens when doctors listen.

Despite over-medication and other communication issues, Jim survived his bout with necrotizing pneumonia. He attributes his good fortune to very proactive family members who monitored his care and treatment. If you, or someone you love, requires hospital care, remain vigilant and use the practical steps outlined above as a guide to better manage care and treatment.

* Quotes in this post are from interviews conducted for my book, Navigating Illness: The Patient Experience, a work in progress. Names were changed upon an individual’s request.


1
Pantilat, S., (2006). What is a Hospitalist? The Hospitalist. https://www.the-hospitalist.org/hospitalist/article/123072/what-hospitalist.

2 Siamak, N., (2017). What Is a Hospitalist? MedicineNet.com. http://www.medicinenet.com/script/main/art.asp?articlekey=93946

3 Stevens, J. P., Nyweide, D. J., Maresh, S., et al. (2017) Comparisons of Hospital Resource Use and Outcome Among Hospitalists, Primary Care Physicians, and Other Generalists. JAMA Intern Med, 177(12): 1781-1787. doi.10.1001/jamainternmed.2017.5824

4 Porter, S. (2018) Patients, Family Caregivers Talk Tough on Care Transition. Annals of Family Medicine Research. https://www.aafp.org/news/practice-professional-issues/20180628annalstransitions.html

5 Kripalani, S., Jackson, A. T., Schnipper, J. L., Coleman, E. A. (2007) Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists. Society of Hospital Medicine. 2(5). doi.10.1002/jhm228