Month: August 2005

MT 3.2

I upgraded to MovableType 3.2 – and it is better than 3.1 .. MUCH better. Had trouble with the new StyleCatcher Plugin .. becasue I set up the /themes directory in the wrong place .. and there is no easy way to go back and re-set it once you do it wrong. Here's how: go to http://yourwebsite/mt/plugins/StyleCatcher/stylecatcher.cgi?__mode=view_config .. and you can reset things. Alas .. there is no link to this on the plugin "settings" page … which is not-so-good design.

Asterisk Review

Tom's Networking Product Reviews : TomsNetworking :

This is a very good overview of the asterisk at home project. I have been using asterisk for about eight or nine months. The at-home version of Asterisk makes it very easy to set up initially and learn how the system works. It's really extraordinary.

We are replacing our four year old telephone system in the office with a system based on Asterisk sometime in the next few weeks. We are waiting for the installation of our T1 line.

I am very excited because it will provide us an opportunity to enhance the services and make things go a little bit more smoothly in the office.

I'll write a quick review of the system tomorrow.

“I never though that I needed counseling until you mentioned it”

It's well documented that primary care physicians help many of our patients with psychosocial problems. Our medical student today was surprised that nearly all of the patients had some such issues that we addressed.

One middle-aged man who suffers from attention deficit disorder was a Polaroid photograph of a man depicted in one of the later chapters of Edward Hallowell's book "Delivered from Distraction" His wife is so angry at him for all of the unfinished tasks in good intentions, and he feels so guilty for his years of inability to "function normally" that it is nearly destroyed their marriage. Medications are helpful, counseling is helpful, but this disorder has certainly taken its toll and he is now working very hard to learn new skills and applied his extraordinary aptitude to this persistent problem.

And an elderly man with depression who told me that "I never thought that I would be someone who was referred to a counselor for problems with my mental health." and as I (insensitive Lee) explained to the medical student who was listening to her conversation, I suggested that he was of the generation that considered counseling to be unusual and abnormal. Turning to her, I asked what percentage of her medical school class had likely sought the assistance of the counselor. She surprised me by responding with what I expect was a rather accurate response "50%." All of this led to a rather interesting conversation of normalcy and "what is normal." he described his personal efforts and hopes that he would be able to "self analyze" his predicament and then give himself advice for how to resolve things. I took a rather different perspective. "I don't speak Portuguese. It's not because I'm stupid or weak or abnormal. It's just that no one taught me.

He looked at me funny.

"So couldn't it be just that you haven't learned the skills to help you with this?"

That's how I see counseling. Patients who do well with counseling are patients who learn new skills to help them cope with the enormous pressures and problems they encounter in their daily lives. By marketing counseling in this way, I think it makes the whole experience more palpable for patients.

Unfortunately, it doesn't always work out that way. Some counselors are excellent and share this vision and expectations. And other counselors (at least as my patients report the interactions) take notes, listen, interject their own personal agendas and so on. So I'm never quite sure what my patient will be getting on and make such a referral. Most of the time things go very well. And that's good.

“My appointment was 47 minutes and he talked for 45 of them”

I am his fourth primary care physician in as many years. He described his sole encounter with his most recent physician something like this: "Hell of a nice guy and he worked as a volunteer firefighter during medical school. And so in talking with him … and out of my 47 minute visit, I think he talked about his days in the fire department for 45 of them. Now that's all fine and I'm happy to chat about the good old days but that's for the coffee shop on Sunday morning, not for my visit when paying him 140 bucks."

This happened on the same day that another patient called me and told me he was transferring care out of my practice. He told me he wasn't happy – frustrated because sometimes it was hard to reach me. "You're a hell of a nice guy Doc – but I need to be able to reach my physician more easily, you know?"

Patient-physician communication. It's at the core of what we do. My new patient was complaining because his previous physician talked too much and listened to little. My old patient was complaining bacuse I wasn't accessible enough to him.

Accessibility is very challenging. I do want to be as accessible as possible to all of my patients but it's so hard to call them all right back instantly when I have 35 telephone messages waiting for me every day. How can we possibly give such personal care to so many people?

When we started our practice four years ago it seemed impossible that we would become so busy as we have in such a short time. And the nurses today were complaining because "we've lost the personal connection" and we're getting too big.

And this may be true. It seems that we always strive for growth, as growth in business and therefore revenue seems to be so important as the pressures of daily practice (rent, salaries, mortgage, looming college education bills for our children) pressure us to maintain revenue and therefore always increase work.

But increasing work simply can't be done above a certain level. For the new patient coming in, I try my best to set his expectations at a level where I can deliver. No, I won't always call him back instantly, and sometimes he will get a callback from my nurse instead of for me and this has to be okay with him. At the same time, if something is very serious and he insists on speaking with me were coming in, I will always do my best to accommodate him.

The 9-year-old I saw this week asked he was my favorite patient. I hesitated, and told him that all of my patients are main favorites. He seemed disappointed. "Well, of course you're my favorite." A sigh of relief from the boy.

So today when a prospective medical student asked me what's the difference between family physicians and other primary care physicians I didn't have much trouble answering her. Yes, internists and pediatricians are compassionate, kind, thoughtful people. But family physicians are explicitly trained to address the psychosocial needs of our patients and those of us who deeply believe that this is an important part of what we do — do our best to live these values.

Blogging again

Beginning on a light note:

I playfully asked a nearly-three year old girl what she was going to be when she grows up.  Without missing a beat … "a woman"  she says.

We'll see if I can sustain blogging this time.  After nearly 4 years of blogging .. I took a break over the summer.  Have been very busy with patients in the office and with some other projects that I hope to write about soon.

Today's reflection is about listening – something that physicians still do rather little of.  Longtime readers (are any of you left?) will recall that I sometimes do reviews of physicians for the New York State OPMC. It's alwasy interesting to do this – and it is usually hard to witness and even participate in the end of a physician's career.   The most recent participant is a kind person, and I think a rather good physician who made some mistakes and is therefore under review.  We talked a lot about listening – and I heard so clearly that this physician felt that LISTENING to the patients is so important – yet so hard to convey in the chart.  It's the quality of a "good physician" that we will never be able to guage from a chart review – or even a physician interview. 

And so I was reminded when this evening – one patient talked for 35 minutes straight, and another asked (when I advised a counseling referral) why I can't be the counselor.

What usually gets documented in the chart is something like " we talked about _____ for __ minutes and greater than 50% of the visit was spent face-to-face counseling"  The 50% part of course is to document for billing purposes that this was a counseling visit and therefore I am billing based on time.  Ugh.  It sure is a bad representation of what really happened.  The richness of the experience – the connection – is not portrayed.   Then again .. so what?