Top Ten Reasons Work is awesome today

So today, I come back to work after 2 weeks of paternity leave.

10: Great to work with an incredible group of Internal Medicine residents. Bright minds and even brighter future

9: Get to work with some really fun and energetic office and nursing staff who are not afraid to say whats on their minds

8: Seeing many different patients means seeing different perspectives on the health care system. This means more insight on coming up with innovative ways to improve the patient experience

7: Get to talk about my NY Giants with my buddy from the cleaning staff (Myron). He’s a cowboys fan 🙂

6: I get to talk to patients. I love to talk. Talking is fun. Conversation is basic human necessity and I thrive on it!

5: I get to continue to learn medicine. Even after years of training, I enjoy learning new things.

4: Work drives me to participate in social media. Tweeting, blogging, Healthtap. It’s all so much fun.

3: Our healthcare system is a disaster and Primary Care (my field of expertise) is under fire. I love a good fight!  The opportunity to create change in medicine is a privilege!

2: Truth is stranger than fiction. I love a good story. My day is filled with stories from patients who never cease to amaze me.

1: No better feeling than after a long hard days work, to open my front door and see my two beautiful kids and loving wife. I love coming home to my family.

Celebrating 30 Days

30 day hospital re-admission rates.


It’s a statistic that keeps hospital administrators up at night. Whether you agree or disagree with the use of this statistic as a quality and reimbursement metric, if it creates change, reduces hospital re-admissions and improves patient care, then in theory I support it.


I’m reminded of Mrs G. She is emblematic of today’s chronic disease patient. She was admitted to our hospital for a congestive heart failure exacerbation, complicated by a COPD (related to her smoking) exacerbation. Throw in some poorly controlled diabetes, atrial fibrillation, depression and generalized deconditioning, this lovely 64 year old lady spent 9 days in our hospital receiving absolutely excellent care. She improved to the point where our terrific inpatient team was able to discharge her directly to home on Tuesday March 27th. From there she was in the hands of her 2 caring daughters and her outpatient doctors at my clinic. And that’s when the clock started ticking.


Tuesday April 3rd: Hospital follow-up. We were able to see her 7 days post-discharge. She was doing well, taking all her medications and her family seemed content with the current situation. Despite how well she was doing, we felt this was the type of patient who could easily decline. We scheduled another appointment in 1 week for further monitoring.


Friday April 6th: Some blood work results came back to our office. Her kidney function had steeply declined. We suspected the high doses of diuretics (water pills) she was taking were the reason. We contacted her over the phone, advised to reduce the doses of her medication and keep her next appointment. She expressed some frustration from constant thirst and generalized fatigue.


Wednesday April 11th: She seemed worse compared to the first visit. She was still thirsty and her legs appeared more swollen. She was also more short of breath. Her atrial fibrillation (irregular heart rhythm) was not controlled.   We adjusted one of her 11 medications to try and counter this. One a side note, she insisted she wasn’t smoking anymore. We ordered more follow up blood work.


Monday April 16th: Her kidney function improved. We called her to discuss these results. She said she felt fine but then her daughter grabbed the phone and from a separate room, explained to us how she hasn’t been following any of our dietary recommendations, and continued to smoke daily while on oxygen! Her family asked us to see her again to bring up these issues at the next appointment.


Friday April 20th: She vehemently denied smoking and drinking excessive fluids, despite having worsening leg swelling and smelling of cigarettes. We increased her water pills back to her prior dose, realizing she had re-accumulated fluid. It was only a matter of time before the fluids got into her lung and she became short of breath again. She was headed in the wrong direction. 


For her next appointment, she came to our office looking absolutely terrible. She couldn’t breathe well, lie flat and her legs were even more swollen. She had been to a barbecue over the weekend and ate salt ridden food without much thought. She had declined to the point where it was no longer safe to try to mange her in the clinic. It was time to head back to the hospital. She shook her head out of frustration as her daughter welled up with tears in the corner of the exam room. Mrs. G asked me if I thought she’d miss Mothers day.


I looked at the calendar and I said probably not. If things went according to plan, I anticipated a short hospital stay. A midst her breathlessness, I sensed some relief in her.


Once I realized what day it was, I too breathed a sigh of relief. It was Monday April 30th.


She was discharged on March 27th. And so I counted 7…14…23…33 days had elapsed. She had eclipsed the 30 day readmission window. My first inclination was to pat myself on the back and hang up a mental banner with the words “Mission Accomplished.” But as I saw Mrs. G getting wheeled away on a stretcher and her distraught daughter trailing behind. I felt very little desire to celebrate having reached this important 30 day benchmark.

Medical Linguistics Failure

    I have a problem with any medical conversation that utilizes the term “Failure” in it.

Acute Renal Failure

Hepatic Failure

Congestive Heart Failure

Failure to thrive ( A personal favorite)

Respiratory Failure

Premature Ovarian Failure

(Name your body part) …Failure.

As an internist where most of my patients have chronic conditions, I deal with many of these “failures” daily. I usually have a pretty good grip on handling the medical aspect of such conditions. It’s the psychological component of such a diagnosis and the counseling necessary, that’s harder.

In my efforts to be an empathetic physician, I’ve likened the experience to as follows.

Let’s say I really like my car, but I don’t know much about how it works. The car starts breaking down for a variety of reasons (partly my fault, which I feel terrible about). Its slower, less fuel efficient, makes all kinds of weird noises, leaks random fluids and generally just doesn’t look as good as it used to. So I take it to my trusted mechanic who after extensive work up tells me I have Name your vital auto part Failure. He offers me this prognosis. Instead of maybe 20 years, the car will last only about another 10 years if I’m lucky. And in those 10 years, I can expect frequent mechanic trips, and I may not have access to that car for weeks at a time. I can expect to try a lot of fixes, some of them quite expensive with questionable efficacy. It’s also our only car, and my family relies on this car for anything and everything.

This would be really upsetting, especially when I connect the dots and come to the conclusion that my car is basically dying.

Patients know what vital organs are, and the term “Failure” implies its demise. Every week, I see patients, anxious and upset about these diagnosis mentioned in passing during hospitalization, by specialists or anyone else with an opinion. So in addition to managing the actual conditions, I have to do psychological damage control by trying to put a positive spin on the situation.

Thank goodness, we are now referring to acute renal failure as acute kidney injury. Besides being a more medically accurate term, it’s so much easier to explain to patients. They are less likely to ask about dialysis now and more likely to ask what injured their kidneys and what they can do to prevent it. 

I move to abolish the term “Failure” from all medical terminology.

It’s medical hyperbole that is unnecessary and frankly makes my job a lot harder! 🙂

 

Shared decision making with patients

    There’s nothing better than sitting down with a patient, going though an entire visit, and  collaborating on a well thought out plan that meets everyone’s expectations. Shared decision making is a wonderful and necessary concept in modern patient care. Paternalistic attitudes are fading away in the medical community as the next generations of doctors continue to get educated on how to manage patients who are very knowledgeable and yearn to be active participants in their care.

    But as patients become more involved in the decision making process, differences in opinion become more prominent. Although these differences can be overcome through open discussion and trust, it is a challenge that is occurring with regularity. In this era of short pressured visits, it’s hard to have long conversations to help meet the patient in the middle when there is a difference in opinion. Litigation concerns also influences decision making immensely, and when there is a debate about whether “to test,” or “not to test,” we might be inclined to align our opinions more towards what a patient wants.

     When a patient adamantly wants something done, and I rationally disagree, it can be a disheartening experience. I reflect on how I’ve spent years studying, training and practicing. I think about how I’ve spent years, not just memorizing facts, but cultivating clinical acumen that integrates multiple data points to compute probabilities of disease states and figuring out likelihood ratios of different tests or medicines and whether the benefits greatly outweigh potential harms and costs. And I have to do this within seconds to minutes in my head, while factoring in patient preference and medico-legal concerns.  I do this juggling act countless times a day, and when I’m wrong it hurts. It hurts my ego a little bit. But it hurts more because you always want what’s best for the patient.

   I’m sure we all have stories of things we regretted ordering for our patients. I can think of several instances of how I acquiesced to a patient’s request that resulted in poor outcomes. Antibiotics that I didn’t want to give, leading to C-Diff colitis, imaging with incidental findings that lead to unnecessary worry, procedures and complications are just a few examples. I can also think of many instances where patients have come to me with positive test results or better outcomes from things I was reluctant to do.

    Whether you are for or against shared decision making, it is here to stay. Patients want to have to more say in their care and that’s a wonderful thing. Involved patients will always do better than detached ones. The modern physician will need a balanced temperament to handle the ups and downs of this two way relationship. Fortunately my ego is just big enough that I return to work every day smiling, feeling good about all my  decisions.  But I do keep my ego in check, mainly by taking some Tums tablets. I’ve realized my heartburn isn’t caused by the coffee I drink, but all the pride I’m willing to swallow and the large heaping servings of humble pie medicine serves me with regularity. 

A patient’s first name.

I often debate whether I should be calling patients by their first name or last name. The gregarious part of me that wants to create a personal family atmosphere thinks first names are better. The professional, respectful part of me sticks to using Mr. or Mrs. The age of the patient also affects my decision. I’m 34, and will not hesitate to use first names with patients younger than me. With a rapidly aging population, most of my patients are much older, and formal salutations are the norm. For middle aged patients, I’m usually torn. Sometimes they’ll just tell me to use their first name. If the issue never comes up, I arbitrarily will switch between formal and informal, depending on my mood, my recollection of their personality, the lunar phase or potentially any other random irrelevant thought process.

Mrs. Silva (name changed) , who despite efforts to hide her age wearing bright ill fitting outfits and loud hats, was definitely 68 years old. No matter how hard she tried to look younger, I always used formal salutations.

“Mrs. Silva, what’s going on with the diabetes?”
“Well Dr. Hossain, I gotta be honest with you, I’ve been cheating more this past month.”

“Mrs. Silva, How’s Mr. Silva doing?”
“Oh he’s good. I keep telling him to make an appointment here. He won’t listen to me.”

“Mrs Silva, did you get your mammogram done?”
“Oh yeah! it’s not due until next month. I’ve already got it scheduled.”

“How’s the breathing Mrs. Silva?”
“It still stinks. I’m still always short of breath and no I haven’t stopped smoking yet Dr. Hossain. But I’m really gonna try these next few months.”

“Mrs. Silva, are you still coughing up a lot of junk?”
“Yeah Dr. Hossain. I can’t seem to shake this cough, even after the antibiotics. And I could’ve sworn I thought I saw a spot of blood in it.”

Soon after mentioning the last complaint, Mrs. Silva was diagnosed with Non small cell Lung cancer. Shortly after, it was discovered she had metastasis to the brain. Because of the myriad of oncology, surgery, neurology, neurosurgery, radiation oncology appointments, and 2 hospitalizations, she wasn’t able to make it for an appointment to my office. A few times she tried to schedule an appointment but cancelled. Throughout the process, we spoke on the phone a few times, and she remained delightfully optimistic and didn’t express any specific needs from me.

Finally, after 6 months, Mrs. Silva made it our office at the urging of her oncologist.. She had lost a great deal of weight and gave up the makeup and bright outfits for more demure, darker and simpler clothing. She lost all her hair but had a closet full of hats for this occasion. Since she was a resident clinic patient, the case was presented to me and I was well aware of all these details even before I walked in the room. I knew I would not be seeing the same Mrs. Silva.

I knocked on the exam room door and with a lump in my throat, ready to discuss some difficult issues.

“Hi. Dr. Hossain.”

I don’t recall what exactly went through my mind when I saw Mrs. Silva in front me, a shell of her former self. But I remember beginning the visit by trying to smile and saying,

“Hi Lily, how are you doing?”

3rd world medicines

       I routinely hear from relatives, how the medical system in my native country of Bangladesh is terrible. As a third world country, access to care, diagnostics and medications is a difficult everyday reality, especially for the millions in poverty. But even for those with money and access to the best care, my relatives often insist they don’t know what they’re doing. They complain to me and encourage their sick family members to find a way to get to a country with more advanced care. They tell me these things as I think about how physicians in 3rd world countries are excellent diagnosticians because they don’t rely as much on imaging or even blood tests. I think about how, despite our advanced technology and monetary investment in healthcare, our mortality data lags behind many other industrialized nations. I respect my elders and their belief in our healthcare system, and graciously accept their praise of my “expertise,” while secretly harboring skepticism towards their beliefs.
       Last year, I saw a 44 year old gentleman immigrant from Bangladesh who presented as a new patient. He had a fairly long list of medical problems for a young man. He had diabetes mellitus requiring insulin, he had a history of a coronary artery disease, high cholesterol, anxiety and depression. He was a pleasant gentlemen, who had been doing well without any particular chief complaint. His primary concern was getting refills on his medications. For the past 6 months, his physician in Bangladesh had been mailing them, but realized this was a dangerous proposition after 1 shipment was delayed and he missed a few doses. I looked at his medication list and didn’t recognize a single name except aspirin. After doing some research online, his deciphered medication list included an Angiotensin receptor blocker (ARB), a beta blocker, a statin, an ssri for depression, and a long acting insulin. It seemed like a very sensible evidence based regimen, and by all accounts had kept him symptom free, without any recent hospitalizations.
        Despite my preconceived notions about his health care in Bangladesh, I was thrilled at how well he was doing. As we were concluding the visit and I began renewing his medications, the dreaded “I” word reared its ugly head. He was a working man but unable to afford insurance yet. Quickly, I realized he would not be able to afford the ARB. I suggested an ACE inhibitor, which he recalled getting a cough from. But he would take it. We found the same beta blocker, except it wasn’t an extended release version, so he’d have to take it twice a day. He was on a brand name statin but now would have to settle for something less efficacious. The SSRI needed to be changed to something cheaper, despite its success. The insulin, despite being generically available here would be far more expensive than back home.
        In the spirit of full disclosure, I was embarrassed to tell my countryman, some of his new medications maybe inferior to what he was already on. He had a perplexed look on his face, waiting for an explanation. I have a hard enough time trying to cogently describe to a medical student or a resident, how our healthcare system operates, let alone an immigrant lay person. I couldn’t give him a straight answer, except to reassure him, we would make this current regimen work. His last question for me was whether he should finish the last 10 days of these 3rd world medicines. My 1st world expert training and sensibilities suggested yes.

Teaching Medicine and Macros

I have the great privilege of being a medical educator. Everyday, I have an incredible time working with  internal medicine residents at their continuity clinic, teaching the art of ambulatory medicine. Our working environment here is academically rich and fulfilling. The name of the legendary Dr. Martin Leibowitz (an iconic figure in ambulatory medicine here) stands outside our conference room as a constant reminder of how medicine is practiced and taught. There is a large oval table at the center of the conference room, constantly surrounded by venerable attendings, interspersed with curious residents, discussing all the difficult cases of the day. There is the constant buzz of organized chaos like a stock exchange that is addictive and keeps things fun and enjoyable.
Although this positive vibe has never changed, the working environment has transformed since I first joined in 2009. The conference table used to be littered with text books like Harrison’s, Netter and a variety of dermatology books. In between the people and books sat  heavy, tattered orange colored paper charts. Some were just a few pages, some hundreds, all documenting a litany of complaints, physical exam findings, test results, insurance documentation, medication lists and well thought out plans by generations past of neophyte doctors. Blue, black, red, green ink on yellow oxidized pages, all fascinating yet often illegible. My intrigue with these historical documents quickly faded, and the burden of having to flip through hundreds of abstruse pages became quite frustrating. The sight of these bright orange charts piled on my desk at the end of the day, became a nauseating reminder of the inefficiencies and dangers of paper documentation. Our electronic medical record (EMR), slated to be released 6 months after my start date, could not come soon enough.
When our EMR era began, it was a cataclysmic event. The process of seeing a patient with the computerized elephant in the room was a culture shock for many attendings and residents. But we integrated slowly, utilizing a light schedule, and a lot of one to one attention for our residents. In 2 years we overcame a lot of the initial technical problems and are on our way to making this a very successful transition. The hardest part of this change for me, had nothing to do with my personal battles with the EMR. Rather, the presence of the EMR created an entire new domain of education I had to provide for my trainees. In addition to medicine, I found myself teaching how to create macros or imbed digital pictures into the electronic record. I’m teaching how to incorporate a myriad of digital tools to better care our aging complex population. It’s become clear that my role as an educator now goes beyond teaching classical medicine. It also involves teaching how medicine will be practiced in the future utilizing technology such as social media and an EMR. As an advocate for the advancement of technology in medical practice, I feel fortunate to have an audience of bright trainees to share my enthusiasm about the future of medicine.
But this technological leap in our practice has had a price. Although the placard of Dr. Leibowitz remains steadfast, the working environment has drastically changed. The conference table often sits empty, replaced by several desktops sitting at the periphery of the room. All the textbooks stand neatly stacked in a corner, collecting dust, as Google images replaces dermatology books, and online resources replaces most texts. The sound of vibrant debate and chart perusal has been replaced by the clicking and clacking of keyboards.
Whereas in the past, 50 % of my encounter time would be spent discussing each case, and the other 50% seeing the patient, my attention is split in three ways now. 33 % each , for patient, trainee and EMR. Now I have less time to get to know and personally connect with each patient. Now there is less time to discuss medicine with my trainees. For new doctors, I wonder if its more important to spend a few extra minutes to discuss how to manage a COPD exacerbation in the outpatient setting, than it is to teach how to multi-click and renew 14 medicines using “E-scribe”. With this whole new domain to teach, given the same time constraints, I’ve had to bring home work quite often, which  is begrudgingly easier now with an electronic record.
Despite these difficulties, I continue to love my role as a medical educator. The day to day issues are minuscule compared to the greater problems in medicine and society. I continue to stay motivated by the idea that my tutelage in medicine and how it interfaces with modern technology will prepare them for a future that will need doctors that are comfortable and successful in the both the real and digital realms.

Welcome

Welcome to the Sanatorium.

I suggest you wear a mask.

 Here at Shab’s Sanitorium, you will see the front lines of medicine. As a primary care physician at an academic institution, I have the privilege of taking care a wide variety of people, illnesses and personalities. Along with this variety, comes the challenge of providing care, to people who are older and sicker, in a failing over priced health care system, ill equipped to handle them.