It’s time to get rid of the “Review of Systems (ROS)”

When it comes to the “review of systems,” I’ve been a natural, a savant, a prodigy you might say.

During my 1st few weeks of medical school, I remember doing  mock interviews with fake patients, long before I learned anything about “HPI,” or “ROS”,  physical exams, billing or anything medically relevant for that matter. As other students stuttered, trying to figure out what to ask a lady pretending to be schizophrenic, I calmly sat in front of her, going head to toe, asking a variety of questions, just to pass the time and to not appear incompetent.

Does your head hurt? 

Does your eye hurt? 

Does your heart hurt? 

Does your belly hurt?

Does your leg hurt?

Does your skin hurt? 

And so on it went for 3 or more minutes, after which my neophyte colleagues and teaching assistant marveled at my ability to methodically pepper her with so many questions with no guidance what so ever. I was born for this; the ability to comfortably take a good detailed history and putting it all together to diagnose and treat anything that might come my way.

As a primary care internist, my ability to take a good history continues to serve me well everyday. But I loathe the “Review of Systems”; that multi-system checklist of endless questions, taught as a necessary skill for every physician, but in reality is just a force fed requisite of every patient visit, created by the billing god Hades himself and fellow deities at the Center for Medicare and Medicaid services.

Knee pain? I will ask you about seasonal allergies. Level 3 billing. Meh.

Hypertension? I will ask you about rashes. Level 4 billing. OK.

Chest pain? I will ask you about your memory. Level 5 billing. Hades is pleased!

In all seriousness, a skilled physician can and should ask about all the relevant systems necessary to make a proper diagnostic and treatment plan. But the reality is, many of us mindlessly go through this ritual on too many visits, without any purpose except to meet documentation and billing requirements. And in the current state of medicine, where visits are condensed to a few minutes, (many of which are occupied by the EMR) spending even 60 seconds going through the ROS check list is a misuse of time and energy. It’s mindless work and that’s frankly insulting to the skilled physician who sincerely thinks about each patient and carefully chooses what to inquire more about.

It’s time to get rid of the Review of Systems, as a 1st step in a major overhaul of what’s required of us for billing.

How parenting has helped me cope with the struggles of modern medicine.

A free moment to read my favorite healthcare blog is difficult to find. The days are packed with complex time intensive patients. In between patients, I struggle to complete documentation and take care of a myriad of tasks, making phone calls and plodding through cumbersome electronic medical records. Then, there’s still  actual paper work to review and complete. I still have to make time to occasionally read clinical literature in addition to interestin blogs and opinion pieces. After all that and braving a long commute, life at home is just as hectic.  For these reasons, I haven’t been reading my favorite blogs and Kevinmd.com posts with regularity. But when I do have the occasional moment to read them, I regularly find posts about the exact things I just complained about. And inevitably,  many conclude with something that goes like this:

” This is not what I signed up for.”

Despite these struggles of the modern physician, I continue to remain optimistic and happy with my career (primary care internist). My ability to cope, stay resilient despite these threats, struggles and challenges is all about perspective. This a perspective that has been forged through a lifetime of experiences, of which my last 6 years as a parent (of 3) has been most paramount to my happiness as a physician.

The joys of parenthood are innumerable. Pick one.

Baby’s first smile. 1st step. 1st words.

Squeezing baby fat. Cute baby dresses. 1st baseball jersey.

1st day of school, playing catch outside, watching a movie together.

This is exactly what I signed up for when I became a dad.

The horrors of parenthood are also plentiful! Pick one.

Sleepless, endless nights. Colic.

Teaching right from wrong or manners, the insanity during bedtime.

Potty training, homework, The teen years.

This is exactly what I did not sign up for when I became a dad…so I thought at first.

But eventually I realized this is what it is to be a parent. The life of a parent, is one of sacrifice and you accept the struggles in order to achieve an important and meaningful outcome. And when you focus on the outcomes and try to recognize the positive moments along the way, you grow more resilient towards all the negative things that come.

I’ve applied this principle to my life as a physician. I don’t need to recount the problems in healthcare. There are plenty of other blogs that catalogue the problems much better than I ever could. But there are also so many good moments.  These are moments that make you laugh, smile, grateful and proud.  And often, I’m tempted in a moment of weakness to try to weigh the good against the bad while trying to answer the question “Why am I here?” That’s when I remind myself, the journey is unpredictable, both up and down. The destination is what really matters.

I want my patients to be well.

I want my kids to be happy.

And as a byproduct of getting them where they need to be, I too will be well and happy.

 

 

 

 

 

 

 

ACP 2017 Thoughts

This post is a bit overdue.

A couple of weeks ago, I had the opportunity to attend the American College of Physicians annual conference in San Diego, California. Here’s a quick recap and thoughts on the event!

As always, a conference is a welcome respite from our day the day work. It’s fun to get away and see a different city. It’s also a nice way to reconnect with old colleagues and meet new ones. It’s also great for career development, refill and recharge that innate desire to learn and improve yourself. Looking back, I’m happy to say this year’s conference (#IM2017) accomplished all of these things.

There’s plenty of medical conferences to attend every year, and the decision to attend ACP came down to a few things. As an internist, ACP is our largest organization and supporting it, both financially and attendance was the sensible thing to do. The long term health of my field depends on ACP to not only teach us through educational programs, but also advocate for us. Internists in my humble, albeit biased opinion are the linchpins of a successful healthcare system that is struggling fiscally and clinically to take care of patients with chronic illness.

Attending ACP also reflects a shift in my career aspirations. For many years now, my interests in medicine have been varied. I’ve split my time, focusing on how I can make health systems better, how I can make trainees better (students/residents) and how I can make patients better. Fortunately, there are many good conferences out there (SGIM, AAIM) that can help academic physicians improve in all these aspects in one meeting.

But after many years as an academic physician, I’ve decided to consolidate my tripartite missions into the 2 things that initially got me interested in medicine; the science and the patients. And with this renewed sense of direction, ACP’s #IM2017 was a great start towards expanding my clinical knowledge and bringing it back to help improve the lives of my patients.

Despite this shift, there is a part of me that continues to want to work to make health systems better. There’s also a part of me that wants to continue to teach. Although an academic institution is the best place to do these things, I believe it can be done in different practice settings. Though students and residents are only found in academic places, “teaching” patients is just as gratifying!

I’ll always remember ACP #2017 as the start of a new chapter in my career. It was an incredibly enjoyable experience, and one that that reinvigorated my love for medicine and practicing primary care as an internist. I’m really excited to bring the latest in clinical innovation to the variety of wonderful and inspiring patients that I serve every day.

Next year, ACP’s annual meeting is in New Orleans! #IM2018

Shabbir Hossain MD FACP

Blending evidence based medicine with patient-centered care.

 

 

Back to basics

It’s easy to get caught up in academic medicine. The variety of work is what always drew me in. One day you’re seeing patients of all ages. The next day, you’re working with medical students and sometimes even undergraduate students. Wednesday, you might be working with interns and residents. Thursday, you’re meeting with office staff and administrators working on practice redesign and quality improvement. Friday, I might be working on faculty initiatives. Every day, brings new and different challenges.

It’s a hectic pace, and one in which it’s easy to lose sight of what’s important and our motivations to get into medicine in the first place. For most of us, what initially drew us to medicine are the patients. For many, especially those that pursue specialty career paths, I imagine it’s not just the patients, but also specific disease states that drive their motivations. As a primary care physician, it’s not the disease, but the entire patient that I’m most interested in. When I look at the myriad of things I do, I’m starting to feel patient care is the most enjoyable part of my week. I really relish the variety of challenges  I tackle every day but it’s helping patients overcome their own challenges which really brings a smile to my face.

Although I consider all my jobs important, this blog post is meant to be a self reminder to keep within my sights what’s most important ; the happiness and success of my patient and parallel to that, my own contentment.

 

 

 

 

Restart

It’s been several months since my last post.

Each time I plan to come back, I keep trying to figure out  how to summarize the events of the recent past.

Do I write about new or old experiences as a primary care doctor?

A new position and experiences working in a safety net  system?

10 years of marriage and how to balance work and family?

The differences between life in New York and Texas?

The challenges of leadership and changing culture?

Politics, change and the new world order?

But I think I realize it’s too daunting to look back.

You just have to think and write in the moment.

Restart and move forward.

 

 

 

Healthcare in the fringes

Yesterday, for the 1st time I had the opportunity to supervise a group of intrepid 1st year medical students taking care of real patients. Working under the auspices of the North Dallas Shared Ministries, these neophyte doctors took time out of their incredibly busy lives to spend an evening taking care of walk-in patients who have no where else to go. It’s an incredible opportunity for these students to start practicing their craft at a very early point in their careers, providing much needed services to folks who lives in the fringes of society.

Although it’s a great opportunity to learn for them, and  a great opportunity to teach for me, the stories that come through this clinic are a testament to the state of healthcare in our country. Here’s a sampling of the stories we heard.

1: A young talented girl that plays 2 musical instruments, attending community college, working a minimum wage job, struggles to cope with her busy life as she grieves the death of a family member in her native country whom she wasn’t able to visit because of the figurative and literal walls of immigration politics.

2: A middle aged mother gets gets a perfectly good course of donated antibiotics for a simple urinary tract infection. But unbeknownst to the medical students, lies the reality that she may never get properly screened and treated for a myriad of other chronic illnesses and cancers because she has no access to real primary care.

3: A young woman with recent admissions to the county hospital, returns with a recurrence of a recent illness. Without access to outpatient care and the resources to run proper diagnostic tests, we blindly treat her illness, keeping our fingers crossed that she doesn’t end up back in the hospital. 

4: A well spoken, intelligent immigrant from East Africa came to us suspecting a tape worm infection. She was quite knowledgeable about the parasites, how she might have acquired it and the commonly used treatments in her native country. We proceeded to recommend treatment only to find out that without health insurance, the 1 dose of the medication costs $250. We scratched our heads, scrambling to figure out options. Fortunately, she wasn’t acutely sick. We advised that while the organization looks for ways to pay for this medication, she contact family back home to mail her a dose. 

This is healthcare in the fringes. No where to go, no one to see, an endless cycle of repeated illnesses and a hope and a prayer for a few tablets that cost pennies elsewhere but too much in America ; the best and most advanced healthcare in the world.

Thanks again to the incredibly bright energetic students who did a great job!

UTSW Medical School

 

 

 

Overnight Call

I wrote this, while sitting at an airport at 3 am, waiting for a 6 am flight

I was very tired.

—————-

Another late night

The feeling is very familiar, though it’s been a long time.

I’ve got a headache and I’m nauseous.

I’m tired, sweaty and I pity anyone who has to be close to me.

I’d like to sleep, but I can’t. I don’t have a comfortable place to sleep. But I also simply can’t, panic stricken by the slightest vibration of my cell phone.

I’m awake, and I see and hear everything, but not everything makes sense. Most things do make sense but I’m grateful I’ve haven’t been pushed harder to make sense of more complex things.

The last time i was in bed, it was 6 AM, 21 hours ago.

I’m sitting in an airport, on a laptop collecting my thoughts of the day that just passed.

When morning arrives, in my fatigued state, I’ll have to talk about everything that happened today. Details are hard to remember in this mental fog, but they mean everything. Details save lives.

I’m not on call, but i remember this is what it feels like.

It feels like it was just a few months ago, (but actually several years ago) I was taking ICU call every 4th night. 6 am to 12 pm the following day. 30 hours. Back then, this was considered, better and more humane than what my predecessors experienced.

Today, I can tolerate the idea of sitting in an airport for 24 hours without sleep. But what I cannot accept is critically ill patients being cared for by young doctors trying to function in my fatigued state.

It really is a good thing that we’re doing away with draconian call schedules in residency.

 

The nights were long, dreary, busy and frightening with the knowledge that as each hour passed,I became more and more tired, and less and less capable of performing at maximal capacity.

The mornings were painful, mindlessly filling out progress notes trying to recall the events, struggling to explain the new stories that rolled in each night.

Walking from bed to bed, surrounded by clean, showered colleagues while wreaking of “Call stank,” I used to count the minutes  when the day would end.

When will this endless night end.

When will I take my last call? when will I never have to do this again?

 

Lady with leukemia in a blast crisis, septic and dying?

When can I leave?

Guy with hepatitis C, and in DIC?

When can I go home and take a shower?

Girl with endocarditis and MRSA sepsis?

When can I crawl into bed?

New admit for ARDS.

I feel nauseous, I can’t breathe, I need some fresh air.

The old-timers can argue of the virtues of long call shifts, the toughness it takes and the sense of responsibility and accountability it takes to perform under duress.

But the truth is, human physiology and billions of years of evolution demand 8 hours of sleep. Patients deserve doctors who function at optimal mental capacity. Doctors are humans  and they deserve not to have their mind stripped, their bodies battered and their soul drained by “call.””

It’s almost 4 am. and my night here in the airport is almost done. I won’t have to do this again for quite a long time. I’m also grateful I never have to do overnight calls.

 

The Imitation Game of Medicine

I love good movies and marvel at Hollywood, their creativity and the ability to capture people’s imaginations. But I also love medicine. I especially find it amusing when I see a movie that parallels my perspectives on medicine.

Recently, my wife and I watched the Imitation Game with Benedict Cumberbatch.

It was terrific.

Briefly, it’s about Alan Turing; a brilliant mathematician and father of modern computing who decoded the impossibly complex Nazi Enigma machine, helped the Allies win WWII, all while battling persecution and oppression as a homosexual in Great Britain.

The basic premise of his challenge was that he had 18 hours each day to manually decipher Nazi military messages from combinations of letters and numbers that exceeded hundreds of millions. It was an impossible daily task for even the most brilliant minds. But he overcame this by designing a machine that could break parts of the code faster than the human mind thereby augmenting his team’s ability to decipher each critical message.

Though not fractionally as brilliant as Alan Turning, my life as Internist has parallels to this story.

Patients are each like their own enigma machine. Underneath, they are an amalgamation of billions of processes (some detrimental) sending out signals that we have to manually decipher in a myriad of ways. Instead of an 18 hour clock, the clock is variable with each patient. And unfortunately despite all our best genuine efforts and available technology  we sometimes fail to capture and decrypt enough of the messages to make an even greater difference.

Essentially, medicine is still waiting for its Alan Turing moment. Right now, researchers, entrepreneurs and others are trying to find the best way to capture all the signals. Wearable technology, mobile phones, genomics, advanced blood and radiologic testing and other modalities are on a crash course towards creating a monumental repository of real-time “Big Data” on each patient. And just like Turning, despite how adept we may seem as physicians, we will need the raw power of digital computing to crack these codes

Once we do this, medicine will be completely different and physicians will be empowered with a revolutionary perspective on how we view disease and manage life.

 

Prescribing Hope

As doctors, we’re usually pretty good at recommending treatments for different illnesses. But we definitely struggle to help patients manage these illnesses. That’s because our mindset from the start of our education is to think about the disease and the correct scientifically validated answer. We rarely explore or think about the very unscientific unpredictable element of disease; everyday life.

Recently, I had the privilege of seeing a patient with one of our bright house staff that illustrated the above point. Briefly, it was a young patient with poorly controlled Type 1 diabetes with repeated hospital admissions from inconsistently managing her complex medical illness. The patient blamed her inability to manage her diabetes to difficult living circumstances related to her parents and her boyfriend

After telling me this very complex medical story, I asked the resident what we should recommend to her. Right on cue, I got the technical answers I needed to hear in an academic setting. We talked about checking blood sugars frequently, increasing her insulin, improving her diet, carb counting and stressing the outcomes associated with diabetes ravaging a body.

I then asked him, how would we going to get her to do these things when it had appeared this advice had already been rendered to her several times before. Not surprisingly, I got a bit of a blank stare.

The first thing we did was recognize she had poor health literacy. With that in mind, our goal was to explain the disease in simple terms, advocating for consistency with just a few recommendations that would ensure she has more insight into her disease while allowing her achieve some semblance of success.

The bigger question was, how do we get her to manage this complex disease successfully long term? But before we figured this out, I asked the resident what made him spend so many hours studying and working so hard as a resident. He told me, it was his hope to have a successful gratifying career while being able to share in a happy and healthy life with his family and friends. With that answer in mind, the both of us went to see the patient.

After spending a few minutes discussing diabetes, I posed a similar question to our patient. I asked her, as a young woman with her entire life ahead of her, what was she looking forward to that could help motivate her to manager her diabetes more aggressively. She kind of smiled, looked down and the floor and couldn’t give me an answer. I pressed her for an answer again, and she told me,

“I dunno, just waitin.” 

She wasn’t waiting for anything in particular, but just for anything good to happen.

With that, it became painfully obvious that she was also afflicted with hopelessness. Though there isn’t a diagnostic code for that, its a chronic illness, that persistent grey cloud and lack of hope that we also need to manage in chronic illness in the poor and downtrodden.

 

 

 

 

 

 

Happy New Year

2015, was a transitional year for me. After making the big move from New York to Texas, my family and I are finally feeling settled, unabashedly happy with our big decision. It wasn’t easy from a personal and professional standpoint to leave family, friends, colleagues, patients, medical students and residents. But after a year of getting acclimated, we can now look ahead to 2016 with a sense of comfort and excitement that we made the right decision and the future is very bright.

Here are the 5 things I’m looking forward to, professionally for 2016.

5: Getting back to Twitter. For many reasons, I drifted away from being active on Twitter. But I’ve started to miss the conversations with people from all over planet who have unique forward thinking perspectives on healthcare and medical education. I also miss the energy that comes from advocating for issues that I’m particularly passionate about such as modernizing healthcare, improving access to healthcare, medical education and voicing my political opinion against bigotry, xenophobia and politicians who want to divide this country. @shabbirhossain

4: Inspiring medical students and residents. I feel part of my job as a medical educator is to show and emphasize to our future doctors that our healthcare system is a mess. We need them to be excellent doctors, but also vocal advocates for improving the system. It’s simply not enough anymore to be a good doctor and work hard. The problems in our healthcare system demand more.

3: Thinking innovatively. I’m going to keep trying to look for small (and perhaps big) ways to practice medicine more innovatively. Medicine, for many reasons has evolved at a much slower pace than most other industries. I believe the system rewards dogma, tradition and self-preservation too much to allow people to think outside the box. It’s a daily struggle not to fall into the grind of simply doing things the way they’ve always been done. But I’m hopeful in 2016, I can get my mind back to thinking more about the future of medicine.

2: Reading. As physicians, we’re always reading. Journals, news articles, blogs etc. But I want to get back to reading more non-medical stuff. I regret not taking more advantage of my liberal arts education in college. The perspectives offered in non-medical literature are critical for a physician to understand people as well the world that exists outside the human body. For example, I’ve been wanting to finish reading Money ball. My hope was to understand Saber Metrics to get an idea of how statistics can be used to understand trends and reinventing “the game.”

1: The Patients: In my short time here, I’ve already been lucky to meet and take care of some incredible patients. This is the best part of being a primary care physician. I get to be a part of the lives of patients from so many different back grounds, each with their own unique story to tell. Young, old, men, women, healthy or sick. I get to see it all, do it all and it’s an incredible privilege.

Happy New Year to everyone and hope 2016 brings good health, peace and prosperity!