Last week, on Thursday, September 7, 2017 -- the same day we signed the documents, we finally got to enter our purchased house! It was a busy afternoon, with movers moving boxes into the house till about 10:30 pm. We slept that night surrounded by boxes -- mostly unopened.
This last weekend, we all spent time unpacking clothes, shoes and trying to put together the bare bones of what we need for our daily lives. There is LOTS more to do.
Coming to work, things are getting a little exciting. I now have a web page on the University at Buffalo website as well as a page on the website of UBMD -- the physician group I am a part of. That page can be found here. There was a meeting today to develop a plan to 'get the word out' about a new physician in the group. This will help build my practice.
Last week, I got to meet Dr. David Holmes, a wonderful Christian physician that leads the global health program for the Family Medicine residency. I hope to get involved with that in the near future too and may be going to Haiti with some medical students and residents over Christmas break.
Monday, September 11, 2017
Sunday, September 03, 2017
Week 4 in New York!
Here we are! It is the beginning of our 4th week in Buffalo, NY. Exciting. Living in this hotel (Staybridge Suites), I have learned:
- I seem to need very little to live my daily lives, in terms of clothes, toiletries and sundries.
- I sleep on the floor very well (but I already knew that). Where I sleep is in the common area of our 2-bedroom suite. During the day, it is where everyone hangs out. Towards late evening, I clear my little area and make my bed.
We are looking forward to moving into our house this week, and I am looking forward to shadowing Genetics, meeting new faculty at a meeting for the purpose and hopefully seeing more patients than I did last week.
We went to church as a family: The Chapel. I learned once again of a remarkable christian Doctor by the name of David Holmes. As it turns out, he is also the Director of Global Health at UB. We have emailed each other, and possibly will be able to meet in person in the coming week. I look forward to new adventures in global health.
I spent the afternoon swimming with my daughter, Phoebe, in the hotel pool. It was a fun time with just the two of us.
We went to church as a family: The Chapel. I learned once again of a remarkable christian Doctor by the name of David Holmes. As it turns out, he is also the Director of Global Health at UB. We have emailed each other, and possibly will be able to meet in person in the coming week. I look forward to new adventures in global health.
I spent the afternoon swimming with my daughter, Phoebe, in the hotel pool. It was a fun time with just the two of us.
Saturday, September 02, 2017
Respect the Patient!
I get angry and frustrated. There is a quote that say, "Don't just get angry! Do something about it!" What am I speaking about?
The center of what I do as a doctor is the patient. Therefore, it follows that listening to my patient, empathizing and trying to understand their concern is integral to caring for them.There seem to be more obstacles to doing this. For example, having to sit in front of a computer and click radio buttons and fill text books and click buttons to meet 'meaningful use' or satisfy some metrics qualification. Having to enter data as 'structured data' versus 'unstructured data' because the system cannot search 'unstructured data' to extract parameters to check off the provider meeting various requirements by payers, QI/QA metrics.
The patient tells a story. The doctor asks questions that add details, catalyzes elaboration of the story. It actually is quite like a story. There is a drama analysis structure called the Freytag pyramid which, simplified, describes drama as consisting of three essential points (with stages connecting them). They are (oversimplified): inciting event, climax, resolution. The clinical case would similarly have a inciting event (chief complaint), climax (acute catastrophic event, point of maximum symptoms) and resolution (cure, management, treatment). In between these points would investigation and evaluation (between inciting event and climax) and management or treatment (between climax and resolution.).
I used to be able to write my notes as narratives with a classic structure of Chief Complaints, History of Present Illness, Past Medical History, Social History, Family History, Review of Systems, Physical Examination, Results, Assessment and Plan. All medical students are taught this.
The structure has not changed, but with the advent of 'structured data', the note reads less like a narrative and more like a series of disjointed bullet points or random phrases grouped under headings.
Patients encounters have changed from being an opportunity for a patient to describe what ails them, into a data collecting opportunity and an chance to 'check the boxes' (colonoscopy? check; Immunizations? Check; Questions about Fall Risk asked ? Check; Depression screened for? Check). I wonder if patients don't feel like instead of having an open window to get a doctor's ear and seek his care, the doctor walks in with an agenda and list of things to do. Won't they feel like instead of listening to them, the doctor has a computer with blanks to fill out in a form, leaving precious little time to actually listen and examine the patient?
I write to create awareness of this quandary. I do get the need for having quality metrics and improving care, but have we become so overwhelmed with filling data into computer programs that we forgot the sensitive precious nature of the doctor-patient relationship? The eye contact, the healing touch (literally), the empathy and connection. The creating of a safe place where a patient will open his or heart and divulge important yet difficult to say information. What of these?
I'm still not sure how I'll do it, but I won't forget:
Respect the patient!
The center of what I do as a doctor is the patient. Therefore, it follows that listening to my patient, empathizing and trying to understand their concern is integral to caring for them.There seem to be more obstacles to doing this. For example, having to sit in front of a computer and click radio buttons and fill text books and click buttons to meet 'meaningful use' or satisfy some metrics qualification. Having to enter data as 'structured data' versus 'unstructured data' because the system cannot search 'unstructured data' to extract parameters to check off the provider meeting various requirements by payers, QI/QA metrics.
The patient tells a story. The doctor asks questions that add details, catalyzes elaboration of the story. It actually is quite like a story. There is a drama analysis structure called the Freytag pyramid which, simplified, describes drama as consisting of three essential points (with stages connecting them). They are (oversimplified): inciting event, climax, resolution. The clinical case would similarly have a inciting event (chief complaint), climax (acute catastrophic event, point of maximum symptoms) and resolution (cure, management, treatment). In between these points would investigation and evaluation (between inciting event and climax) and management or treatment (between climax and resolution.).
I used to be able to write my notes as narratives with a classic structure of Chief Complaints, History of Present Illness, Past Medical History, Social History, Family History, Review of Systems, Physical Examination, Results, Assessment and Plan. All medical students are taught this.
The structure has not changed, but with the advent of 'structured data', the note reads less like a narrative and more like a series of disjointed bullet points or random phrases grouped under headings.
Patients encounters have changed from being an opportunity for a patient to describe what ails them, into a data collecting opportunity and an chance to 'check the boxes' (colonoscopy? check; Immunizations? Check; Questions about Fall Risk asked ? Check; Depression screened for? Check). I wonder if patients don't feel like instead of having an open window to get a doctor's ear and seek his care, the doctor walks in with an agenda and list of things to do. Won't they feel like instead of listening to them, the doctor has a computer with blanks to fill out in a form, leaving precious little time to actually listen and examine the patient?
I write to create awareness of this quandary. I do get the need for having quality metrics and improving care, but have we become so overwhelmed with filling data into computer programs that we forgot the sensitive precious nature of the doctor-patient relationship? The eye contact, the healing touch (literally), the empathy and connection. The creating of a safe place where a patient will open his or heart and divulge important yet difficult to say information. What of these?
I'm still not sure how I'll do it, but I won't forget:
Respect the patient!
Integrated Care
Coming from Marshfield, WI to Buffalo, NY has introduced me to many changes:
- In Marshfield, basically, the Marshfield Clinic was a place where most patients got ALL their medical care. That meant that if I wanted to know if someone was up-to-date on their vaccines, or had had a pap smear or colonoscopy recently, I had only to look in the same electronic health record I was accessing as I was seeing the patient. In contrast, in Buffalo, a lot of the patients I saw this week had 'blank' medical records in our EHR. This is because they had gotten their previous (and some current) care elsewhere in the city -- with different medical groups. In order to determine what had occurred there, I would have to request medical records from these multiple providers and the documents would arrive by fax and be scanned as image documents into their EHR in my practice.
- Marshfield: one central healthcare provider in town with all specialties belonging to that practice (the Marshfield Clinic). Buffalo: a doctor almost literally on every street corner, competing medical groups, specialties spin-offs, stand-alone ambulatory surgery centers not affiliated with a major hospital. Care is dispersed, distributed and in my opinion, fragmented.
Commentary: I would argue for integrated care within a system. Sharing medical records seamlessly and allowing open conversations with practitioners treating the same patients would benefit the patient and improve their care. The old phrase "It takes a village to raise a child" seems to apply here. When I hear the term HIPAA (Health Information Portability and Privacy Act), I feel it means that a patients health information (PHI) is portable. Unfortunately, it does not seem that at all. The Privacy part is magnified in practice so large, I think it hinders communication between patients and their doctors and most often, doctors treating the same patient don't communicate with each other -- either in person or through congregating around a common patient chart.
If I were in charge...
Okay, here's my grandiose thinking. The patient should have a medical record in a common platform electronic format that is in their possession. They take it with them to every appointment with any doctor anywhere (now that's portability). The doctor plugs this structured information into an electronic medical record shell to view it. He/she updates it with their contribution -- labs, imaging, examination findings, consult note, whatever. The record returns to the patient, enriched with data and care that supplements (not duplicates, not ignores) what is already present.
Alternatively, the government hosts a secure patient database that is accessed securely by all providers and with a MyRecord portal for patients. I believe some countries (Iceland?) already do this. Of course, they have a single payer system too.
We spend an inordinate amount of time and effort to obtain patient records and then they are in a format that cannot be plugged into our EHR software to yield structured, searchable distributed data (labs going with labs, imaging with imaging, etc).
(Sigh!)
Until this happens, I will continue to try to get medical records from elsewhere and enrich my patient's chart. However, I will also try to canvas my patients to get their specialty care with associates in our multi-specialty group practice, if only because we share the EHR and can speak to each other.
The end of Week 3 in New York
I'm still not very busy. However, I have had fruitful discussions with Genetics about 'shadowing' their providers for a while, to get some of their complex adult patients into my practice. I saw patients this week, and am feeling a little more comfortable with the EHR software. We heard some news this week: our closing date for our house was supposed to be on September 5, but since that is the day after the long Labor Day weekend, it'll probably be on September 7, according to our attorneys (yes, in New York apparently, one needs an attorney to buy or sell a house). My wife is very disappointed by this.
We have however, had a good stay at Staybridge. The breakfast is very good and the facilities have been excellent. Living out of a suitcase shows me (can't speak for the rest of the family), how many things we actually use on a daily basis.That is an interesting lesson.
We have however, had a good stay at Staybridge. The breakfast is very good and the facilities have been excellent. Living out of a suitcase shows me (can't speak for the rest of the family), how many things we actually use on a daily basis.That is an interesting lesson.
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