Month: February 2013

Medicine is a biologic AND social science

 I’m embarrassed to admit but I had cliched notions of why I wanted to be a doctor in my formative teenage years. Get ready to cringe folks.

 I want to help people! “
” I love science! ” 

I decided to major in Biology as an undergraduate because I believed medicine was primarily about biology.
I did the bare minimum liberal arts courses as an 18 and 19 year old. A little bit of economics, a little bit of European history, a little bit of English and a little bit of philosophy. I didn’t take any courses in law, ethics, psychology and anthropology. I didn’t appreciate its value and moved on to medical school with the goal of helping people, utilizing my expertise in this biologic science.

Despite medical school and residency programs’ feeble attempts at educating trainees on taking care of the “whole” patient,  most young doctors today cling to the notion that medicine is primarily a biologic science.This is despite the fact that we have young doctors with many different degrees and backgrounds. I’ve seen this manifest in many ways.

I’ve spoken to many medical students to ascertain some of the motivations behind their impending career choices. Many choose careers in surgical specialties because of their love of the surgery itself and its hands on approach to managing disease. I’ve had students tell me they’ve pursued certain career paths because they are more comfortable in fields that put less emphasis on patient contact. Even in my own field of Internal Medicine, students seem to love the academic discussion on disease diagnosis and management. No matter what field they choose, there seems to always be an underlying appreciation for the life science aspect of disease.

With post-graduate trainees (residents) the story is similar. Many are choosing sub specialty fields because of their appreciation for the specific subset of diseases they get to manage. Even those staying in internal medicine, are largely choosing hospitalist careers for many reasons including an interest in managing the acutely ill. I’ve come to the conclusion, a common fundamental thread in career decision making is that same trite statement and assumption I started my own career with; ” I love science. “

But medicine is not just a biologic science. The concept of treating the “whole patient” simply means medicine  is both a biologic and social science. But our training and attitudes don’t reflect that. I often hear students and residents mention an aversion to the “social ” issues of a patient. It has become largely acceptable for specialists to let hospitalists and primary care physicians handle the “social” issues. Even hospitalists will sometimes defer social issues to their outpatient counterparts.

This cynic will look at this and call it “dumping.” No matter the perspective, neglecting the social sciences aspect of patient care is simply incomplete bad medicine.

How do we change this?
For starters, we need to change the image of medicine as a field for life science lovers. We need people that also love the human aspect of disease.

 Secondly, we need to value social sciences education when we assess potential for medical school.  I think we are already trying to do this. But despite our subjective efforts to  identify well rounded students, the objective admission criteria is weighted heavily towards basic sciences grades and MCATS.

Thirdly, medical schools need to incorporate the social sciences in their curriculum to further augment skills to be a complete physician. I would even advocate for more flexible curriculums that allow medical students to get dual degrees such as an MD + (JD or MBA or MPH).   This would also be the pipeline where all our physician leaders would eventually come from.

 Finally, education in post graduate training  needs to emphasize the importance of a patient’s social situation and how it relates to clinical outcomes. Concept’s like the ” Patient Centered Medical Home” and “Team Based Care” utilize concepts from the social sciences to improve the way healthcare is delivered. Residencies need to teach this, and accreditation bodies should look for expertise in such things before giving the green light to practice medicine independently.

I realize I’m advocating for something I didn’t have. It just means instead of doing the usual Internal Medicine CME stuff, I’ll be getting in touch with my liberal arts side to continue to become a better physician.

Addendum.
New York Med, Non traditional path to medicine

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The hardest thing in Medicine today


I can’t imagine how difficult it was to practice medicine in the “dark ages”. I would feel helpless.

In the pre-antibiotics era, I can’t imagine how difficult it was to care for a patient with an infection.  Without rapid high fidelity imaging, I wouldn’t know how to manage patients with acute abdomens, strokes and many other conditions. 

There’s a lot modern medicine affords us that we take for granted. With relative ease, I can prescribe potent antibiotics and order expensive imaging without putting much thought into it. Such cavalier “easy” medicine would seem unfathomable to our physician forefathers and our current colleagues who struggle caring for patients in the 3rd world. 

Recently, in our office one of our bright conscientious resident physicians discussed a case about an elderly demented patient whom he suspected had pneumonia.  He wasn’t sure the patient had pneumonia because the history and physical exam wasn’t convincing. Because the patient was frail and elderly, and the diagnosis was uncertain, he wanted to send him to the hospital for further diagnostics, monitoring and management. An ER visit would guarantee blood work, imaging, IV antibiotics, an admission to our medical service and more importantly a clear conscious. In my opinion this was the easy way out. 

After discussing a few academic issues related to risk benefit ratio of the different ways we could have managed this case and also taking into account patient and family preference, we decided to send the patient home with an attempt to manage him as an outpatient. 

I explained to the resident, who is extremely intelligent, compassionate but also lacked confidence (understandable for a trainee) the easiest thing in medicine today, is to do. It’s very easy to do anything or everything. But he didn’t go through years of education and training, to make easy decisions. As doctors we are counted on to help make the difficult decisions. In modern medicine, the difficult decisions are not related to what we can or should do. The hardest thing in medicine today is the decision to do less, or sometimes nothing at all. 



A discussion on behavior change ( Part I )

I had a very interesting discussion with a frustrated resident. After dealing with a difficult patient with multiple chronic diseases, he expressed frustration about patients that don’t follow through with our recommendations. He took a big step in identifying some of the problems in how we counsel patients. 
 When we see a patient we are quick (and good) at pointing out all the bad things that could happen if a behavior change isn’t adopted. 
   ”Ifwe don’t do a better job controlling your diabetes, X, Y and Z could happen.” 
This is what our current training in medicine advocates. Our education revolves around the diseased state, how to treat it, how to cure it and to a lesser degree, how to prevent it. And when we talk about prevention, the motivation is based on what the physician values. In this case the physician values theX, Y & Z” outcomes, but patients may not put as much stock in that. 
The resident suggested shifting motivation to what the patient values. 
  “If we do a better job controlling your diabetes, you will feel better.” 

“If we do a better job controlling your diabetes, you are more likely to make it to your grandson’s wedding.”
This was terrific insight from a young, inexperienced doctor. And with that, he touched on one of the sentinel questions in modern medicine. What is the best way to enact behavior change in medicine?
There are several elements to it. The most fundamental prerequisite is to know your patients well and what they value. By understanding what they value, we can tailor behavioral change advice that is meaningful on a personal level and therefore more likely to succeed. This is a fundamental concept in how we should be practicing medicine. It is also a concept we don’t emphasize enough in medical school and residency training. 

My discussion with the resident carried on much further. In subsequent parts, I’ll share some of the  technical aspects of behavior change that we discussed and how to incorporate it in modern medicine. 

A patient centered medical home for our residents

We are in the process of setting up a patient centered medical home(PCMH) for our internal medicine resident continuity clinic. For the longest time, the PCMH seemed like a nebulous concept for me. If someone asked me what it was, I’d have a difficult explaining it. But after spending time reading the literature, I have a better idea . But now that we’re building it for our residents, we have to explain it to them. This can always be a challenge, especially when the PCMH redefines how we deliver care. Residents are already used to doing things a certain way, and concepts that require behavior change and extra effort can sometimes be a tough sell (for trainees and patients for that matter).

In patient care, it’s easy to get caught up in the details. I often advocate that the residents take a step back, and give the patient a big picture perspective. This is my big picture perspective on the PCMH.

It’s starts with the notion that the way we practice medicine isn’t very good. Considering, how much money we invest in healthcare, most metrics indicate we don’t get nearly as much for our healthcare dollars as many other nations do.

I liken our health care system to a custom made exotic car. It’s expensive. It’s got components of all the great cars. You take the best parts of a Ferrari, Aston Martin, Porsche, Mercedes. Lamborghini, Bugatti, you’ve got our health care system. It’s potential is incredible. Despite it being an incredibly powerful machine, it is limited by one crucial factor. It is the driver. We have terrible drivers.

And that’s what I want the PCMH to be for our resident trainees.. It’s driving school. It’s learning a new and better way to drive this car. It’s learning about how all the custom made components work together. It’s about making each patient’s journey in this vehicle a better one. It’s simply about delivering better care.

A wolf in the sheep’s pasture

We had a lawyer giving medical grand rounds today.
It had a malpractice flavor to it. It was about some of the medico legal pitfalls with our adoption of an electronic medical record (EMR).

Normally, the doctors are the sheep sitting in the courtroom den and the lawyers playing the part of the wolf. It was the reverse today.

I’m going to stay true to my promise to be succinct. (I could rant a lot about today’s talk. Some of it is on twitter!)

There wasn’t any substance to the talk. It was basically “be careful of this ” , “don’t do that ” , “you have to be able to defend this.”

Ultimately, the verdict was this. Despite the EMR being a major advance in how we provide care (my opinion), it’s opened up a myriad of holes that our legal system can take advantage of to find fault in our care for patients.

I can cite numerous examples of how ridiculous this train of thought is. I can identify the hypocrisy in many of the examples this lawyer cited. But I’m not building a case. Perhaps if I was a lawyer, I could create an elegant argument against today’s grand rounds in the hopes of changing the minds of the powers that be.

I’m just a doctor.
I’m just a primary care physician.
I don’t have time to be a lawyer. I’m too busy taking care of sick people.

I can only only operate within the confines of our legal system. I can only continue to advocate for a future of medicine that is not constrained by our legal system and continues to leverage technology to improve the health care system.

A post to change all my future posts

I’m new to blogging.
I sometimes have verbal diarrhea, and spill whatever thoughts come to my head.

And then, when I look back at my posts, I realize how annoying it must be to read some of  them.

They’re long!

Thanks to social media, twitter etc, I’ve run into some amazing blogs out there, many of them written by physicians like myself. So many of them are amazingly insightful. I love it.

The great ones have a few things in common. One of them is that they are succinct! In this digital era, where our attention spans are short, this medium (blogging) needs to be concise and to the point.

So here’s an acronym and reminder to myself. K.I.S.S.
Keep It Simple Shabbir!

And here’s to all the bloggers out there who do an amazing job, thanks!

And to everyone out there reading my posts, appreciate the support and look forward to sharing more by sharing less!

Big Data, chronic disease and the future of medicine.

Every day, I make important decisions with my patients.
They are calculated decisions from integrating a lot of information.
Some of that information is subjective, but in modern medicine, a lot of it is objective. The history, the physical exam, blood work, radiology; I integrate all the data to make good sensible decisions. This task becomes more challenging when patients have multiple chronic diseases. Each disease generates countless points of data that need to be considered. Putting all of this together in a 20 minute office visit is very difficult. One way I try to overcome this problem is by scheduling multiple visits and try to peck away at select problems on each visit.

“Team-based” care is also a popular buzz word in medicine. In team based care, multiple people from different disciplines get involved to create comprehensive care plans for each patient. Each team member  collects  more data that is pooled for the team members to make better calculated decisions.
It’s a lot of data collection, but is it enough?
For the chronic disease patient, it isn’t.
Chronic disease persists 24 hours a day, 7 day a week. From genes, to cells to psyche, the damage never stops in the chronic disease state. It’s impossible to catch and fix every bit of damage being done to the mind and body
But instead, we see patients at an arbitrary interval (e.g. 1 or 3 months) and try to identify some basic root causes and address the damage after the fact. It is an exercise in futility. 
But technology will help bridge this gap between the perpetual chronic disease state and physician intervention through the generation of medical “Big Data.” 
An example of this is self-monitoring or self-tracking. We cannot monitor patients 24/7, so patients will utilize technology to watch themselves. Self-monitoring is in its infancy. Blood sugar, blood pressure, heart rate are just the beginning. Technology will evolve to create monitoring mechanisms that cheaply and efficiently collect a tremendous wealth of information from the patient’s home. The data will be better than static information (e.g. a series of blood sugars readings) but dynamic; static data that is automatically trended, analyzed, cross referenced against other monitored variables. In the end, the physician will not receive a series of blood sugar readings. Instead it will be a comprehensive report that tells us what’s happening in the patient from gene to psyche and everything in between. Initially it will be a tremendous volume of information, hence the term “Big Data.” But it will evolve to eventually become concise patient centered “Smart Data.”  
The whole idea of a wired chronic disease patient and 24/7 monitoring may seem like science fiction right now. But I have faith in the world’s innovators out there; to share my vision and one day give me the tools to provide the kind of care and intervention my chronic disease patients deserve.