A Stranger in Your Exam Room

It is often difficult for patients to discuss personal issues with their doctors. Thanks to electronic records, it just got a whole lot harder.

Electronic Medical records have been a major disappointment. In survey after survey doctors tell stories of unmet promises and unexpected failures. While electronic prescribing, data collection and legibility of records are a positive, patients tell of doctors never looking up from the computer screen and of more time waiting and less time with the doctor. Doctors feel detached from patients, are stressed when they fall behind, and wonder when the promise of easily accessed data from other doctors will ever be realized. Some of these difficulties are understandable but there is one negative aspect of electronic records that is particularly troubling to patients, especially those dealing with intensely personal issues such as mental health and family conflicts. Many doctors are hiring “scribes”, people whose job it is to enter data into the computerized record on behalf of the doctor.

For some physician’s this is a matter of survival. Inefficient medical software and limited computer and typing skills have resulted in plummeting physician productivity. Declining reimbursements and rising costs make it impossible for doctors to cut back on volume to allow them to enter data themselves. They see no choice but to hire someone to do the work for them. When paying someone $25 an hour to enter data allows you to see an additional 6 patients a day, the math is easy. Spending $200 to make $600 is a return on investment that cannot be ignored.

While physicians are comfortable with an extra person in the exam room during the interview, patients are not always in agreement. Privacy laws and confidentiality policies do not change the fact that this extra person may learn things about a patient's marriage, sex life, depression or drug use that the patient wishes they hadn't. There is a real risk that as a result some patients may withhold information crucial to their care.

So what can be done? At the moment options are limited. Patients have a right to ask that a scribe not be present, but this may strain the relationship with the physician as it is essentially asking the doctor to fall behind in the office.

Some physicians have addressed the problem by charging extra fees to patients to cover the costs of longer visits. I have seen physicians charge from $900 to $3000 dollars a year per patient to be a part of a practice that schedules fewer visits per day, giving more face to face time with the doctor. Unfortunately these membership fees are not covered by insurance and out of the reach of many families. Doctors who participate in HMO plans are contractually banned from charging such fees.

As with many medical conditions, there is no readily available treatment or cure. For the moment, doctors and patients will need to learn to live with the pain and hope things get better over time. I am not sure they will.

-          Bart

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The Wisdom of Gramps

I have spent much of the last several days thinking about my grandfather. As is often the case when a loved one is lost, his words and stories have filled my mind. He was a man who loved to laugh and tell jokes but I do not think any of his jokes were new. I doubt if any of them originated after 1955. Here are some of his favorites-

Whenever anyone asked how he was his standard reply was, "I'm older than I've ever been."

When one of his grandsons would walk in he would often say, "You get any better looking and you'll look as good as me!"

If I asked him if he could afford anything his answer was always, "I've got money I haven't spent yet!"

A few days before he died, I suggested it would be easier to put all of his money into a single account. Gramps replied, "You want to put both dollars in the same place?"

He always introduced himself by saying, "I'm Les. With one "s"

He told me several times what he wanted on his gravestone- "Les is no more."

I still laugh at the silliness of his jokes, but it is a serious comment he made when I was 10 years old that has most been on my mind. One summer my cousin and I spent a few weeks with our grandparents. We spent most of our time trying to one up each other. One morning we were debating who was greater and telling stories about why and how we were better that each other. Gramps overheard our friendly argument and called out from the other room.

"If you really were great you wouldn't have to tell anybody. They would just know." That lesson about  greatness, that it is based on your actions and not your words, has never left me.

Thanks Gramps.

- Bart

A Love that Lasted.

I said good-bye to my Grandfather today. He was 97. His last words were to my Grandmother, the love of his life for 77 years, "I love you, Sweetie." My grandfather was not a perfect man, but if a man’s life is measured by the love he has for his wife, he was a good one.

It was just 12 days ago that Gramps was discharged from the hospital. As he was deemed too weak to return to his assisted living facility I scrambled to find a nursing home near me that would accept him and my grandmother. His long term prognosis was poor as the combination of age, a muscular disorder and perhaps some small stroke had rendered him unable to protect his airway when he swallowed. We all knew it was just a matter of time before aspiration pneumonia would take him.

He was admitted to the skilled nursing facility late on a Saturday. I took my grandmother to visit him the next afternoon. My brother and cousin were there with him when we arrived. Gramps had been dozing off and only marginally engaged in conversation. That all changed when I wheeled my grandma into the room. His face lit up when he saw her, he was fully awake and smiling broadly. I pulled her wheelchair up beside his bed. He quickly took her hand and said, “I love you more than ever!”

For the next 10 days they shared a room together, their beds side by side, TV’s turned on to Fox News, their favorite channel. During the days they went together to physical therapy sessions. She worked on regaining sufficient strength in her leg muscles, he worked to be able to sit up in bed. When she finished her exercises she remained for his session, acting as cheerleader to get him to work harder. The staff told me that he did better when she was there. He always did better when she was there.

She is still there, but he is gone. Now she will have to make do on her own, a daunting challenge after 77 years. It will be a struggle for her but I pray she will find comfort knowing that she was truly and completely loved. Even more, I pray she will rest in the knowledge that she will see him again. When God calls her home, I expect my grandfather’s face will again break into a smile. Heaven will be even more perfect, because she will be there.

Bart

Infertility and Punching Friends in the Face

“If any one says, ‘My husband just looks at me and I get pregnant’, walk up to them, punch them in the face and tell them your doctor told you to do it.”

I was talking to a new patient who was dealing with infertility. She and her husband had been trying to conceive for over a year and she was feeling the strain. It seemed her life consisted entirely of ovulation kits and menstrual cycles. The spontaneity of romantic intimacy had given way to planned intercourse on designated days, their sex life governed more by hormonal cycles than love.

As Lisa and I had also struggled with infertility I was able to empathize. I said, “What makes it really hard…” and she finished my sentence for me, “It seems like everyone around you is pregnant!”

I gave her a second face-punching instruction, telling her she could also smack anyone who said, “Just relax, it will happen.”

We talked about how no one who has not dealt with infertility can fully understand how hard it is, and how we tend to suffer in silent loneliness for fear of being a “downer” to our friends. We talked about the fear of never having children and the rollercoaster ride of emotions and the tense days each month as the day a period was due approached, the hope and fear that build up simultaneously.

At the end of the visit I asked her if I could say a prayer for her. I put my arm around her shoulder and asked God for peace and hope, and asked Him to bless them with a child. I also asked that He help her trust Him regardless of the outcome.

When she left, nothing about her circumstances had changed, but it is my hope that she left encouraged with the knowledge that she was not alone, that someone understood, that someone cared. Sometimes that is the most important medicine.

-          Bart

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When a Patient Wants to Die

What if he asked me to help end his life?

George was dying. I did  not expect him to last more than a few weeks. The esophageal cancer had spread to his liver and to his lymphatic system, mutated and spread beyond the reach of all known treatments. His esophagus was narrowed to the point where solid foods were impossible to swallow and he was starving. The impact of the cancer on his digestive system had resulted in intractable nausea. None of the four anti-nausea medications he was taking had made a difference. Every day was miserable. All pleasure was gone from his life and he was simply waiting to die.

He signed up for hospice care to ease his passing. He was too weak to come to the office so I went to his home to see him. He was a shell of the man he once was. He was once obese but was no longer. He had lost over 100 pounds, his clothes hung loose and his face was drawn.

During the hour I was in his home we discussed many things. He asked me many unanswerable questions-, wondering what caused the cancer, what would have happened if the specialist he had seen had made the diagnosis earlier when he first had trouble swallowing. He asked how long it would take for him to die. Having provided care to many hospice patients over the years I told him that only a foolish doctor would deign to predict a time of death. Death comes when it comes. Sometimes in comes in days, other times it comes in weeks. All I could promise was that I would be there for him, that he would not suffer.

Waiting can become the hardest part of dying. Once the inevitability of death has been accepted, when the goodbyes are said and the prayers have been made there is nothing else to do but wait, to watch each change in symptoms and wonder what it means, to wonder if the final countdown clock has started to tick or if it is just another meaningless change. 

For many patients and families the waiting is unbearable. As the suffering increases and the end approaches it is natural to ask, “Can we just do something to end it?”

Because physician assisted suicide has been illegal in California I have never had to directly answer the question. This could change at any moment, as the governor has signed a bill that would legalize the practice. When the law is implemented it will be legal for me to give patients like George a lethal dose of medication. The question of "When?" will become answerable and the agonizing days of waiting avoided. Family and friends could know the time and place and plan accordingly. Everyone would feel a sense of control.

And my role as a physician would change forever.

For patient's like George  it seems straightforward. He had at most a month or two to live, and his suffering was real. Why not provide definitive closure for such patients? What is the harm in providing a quick and easy passing?

George's case provides an answer to these questions. Under the law as written, George would have been a candidate for assisted suicide 4 months ago, when he was first diagnosed with the aggressive cancer. If he had not elected to attempt treatment his life expectancy would have been less than 6 months and he would have met the conditions of the law. Any doctor could have ended his life any time he wanted. He could have been given a large dose of morphine or other medications and the months of suffering avoided.

He also would have avoided hundreds of conversations with friends and family, including the spiritual conversations he had with me and others. A professed atheist, he specifically asked for prayer and if I would advise him spiritually as he went through the process of dealing with his disease. That 4 month process changed him. He became a different man with a different perspective. I would not have wanted to take that from him, nor should anyone.

Many will say that it should be the patient’s choice. In a godless world where man is the ultimate arbiter of his fate this makes sense. If there are no enduring consequences, if there is no ultimate meaning in life, if there is nothing good that comes from suffering, these choice advocates are right.

But we do not live in a godless world and man is not god, as much as many may wish that we were. Death reminds us of that.

As a Christian physician I will not play the role of God, I will not help a patient end his life. What I will do is relieve his suffering. I will aggressively treat his pain without reservation, even if that requires middle of the night visits. I will come to his home to pray for him, sit with him and comfort him, and do all I can to facilitate a death that is filled with dignity and comfort, knowing that each moment, even the ones filled with pain, provides an opportunity for love, reflection and faith.

- Bart

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