A Cancer Diagnosis- Missed

It was cancer and I missed it. I not only missed it, I missed it badly. The thought of malignancy never entered my mind. He had come in a few months earlier complaining of pain along the lateral aspect of his thigh. He was tender over the iliotibial band so I diagnosed him with iliotibial band syndrome and sent him to a physical therapist. When he came in a few weeks later reporting improvement I was confident I had made the right call.

The improvement did not last and within the month he told me the pain had worsened. Perplexed, I referred him to an orthopedic surgeon. The orthopedist ordered an MRI of the area and the accurate diagnosis was made. He had a tumor in the muscle of his thigh and it was malignant.

I never saw the patient again. Our final contact was over the phone. He had called me to tell me he was firing me as his doctor and would be seeking care elsewhere. He was convinced that it was my fault the diagnosis had been delayed.

I told him I understood his anger and frustration and that I wished I had thought to order the MRI sooner. I explained that he was the first patient with muscle cancer I had ever encountered and that the diagnosis was rare. Because it was rare, muscle cancer was not something high on my list of possible causes. I told him that doctors typically start with common diagnoses and then move down the list, that if doctors began every course of treatment searching for the extremely rare serious condition they would not be good doctors. He was not satisfied with my explanation.

He was not the only patient to leave my practice over his diagnosis. His wife and a family friend joined in the exodus, convinced that I was a “bad” doctor. I grieved at their decision and wondered what I could have done differently.

The truth is there was nothing I could have done. I am a human being with all of the imperfections that come with it. Medicine is to broad and the body too complex for any one doctor to master it all. Perfection is impossible.

In spite of my years of education and hard work, each day I find myself facing the reality that I will miss things. I hate this reality and it is a source of intense fear and anxiety but it is inescapable. I will occasionally make mistakes. Like every working person in the world my only option is to do the best I can every day and hope for the best. When my best is not good enough I have not choice but to accept the outcome and rely on the grace of others. More importantly, I need to extend the same grace to others when they fall short. 

-Bart

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Modern Medicine isn't Always Modern

7 days after falling off of his mountain bike he decided his shoulder injury was more than a bruise. He had significant pain and swelling over his collarbone so I ordered an x-ray. He walked in the next day with the images on a CD. My staff loaded the images and the fracture was readily apparent. While the fracture was obvious I was not certain about the treatment. I wondered if surgery was indicated.

I wanted a quick answer, so I took a picture of the image and texted it to my orthopedic surgeon colleague. The answer came back in minutes- the injury needed surgery. Two quick test messages and instead of waiting a few days for an answer the patient walked out of the office knowing immediately what was needed.

A few days later I received a call from the daughter of a patient with dementia. Her mom was not doing well. The daughter said she was more confused, unsteady on her feet and declining. As it was hard for her to bring her mom to the office she wondered if I could make a house call. My willingness to stop by the board and care where the patient lived was blunted by geography. The patient lived almost 20 minutes away. The 40 minute round trip was too far to go during a lunch hour. As the daughter had an iPhone I proposed a compromise. I suggested a FaceTime consult. Two days later I had a “face to face” conversation with the patient. She had improved slightly but was still unsteady in her gait. I ordered an in home physical therapy assessment and made arrangements to check on the patient the following week. The daughter was greatly relieved.

Another evening that week I received a text message from a patient. He had what appeared to be a blister on the surface of his eye and was wondering if he needed to go to the emergency room. I had him send me a photo and quickly made the diagnosis of chemosis, edema of the surface of the eye caused by an allergy. There was no reason for him to go to the emergency room for the problem and I promised to see him in the office the next morning. Two text messages taking less than a minute saved him a lot of time and expense.

Friday afternoon brought another text medicine diagnosis. A patient was smoking and wasn’t paying attention. Hot ashes fell from the tip of the cigarette and landed on her chest. The resulting burn was painful and she was worried about how to treat it. She called the office and the receptionist gave her the number to our office iPhone. Shortly thereafter I was looking at the photo and texting back treatment instructions.

Interactions such as these should represent the future of medicine. They are accurate, efficient, cost-effective and convenient. They are also incredibly rare, as very few physicians offer such services. One may wonder why these innovative services are not more commonly provided. The answer is simple. Doctors are rarely paid for them. Insurance reimbursement lags innovation and insurers have not figured out how to pay physicians for electronically delivered care.

The dominant insurance reimbursement model is based on office based services for in person care. Patients are weighed, vital signs are measured and the patient is questioned and examined and providers are compensated based on the complexity of the condition treated. Doctors typically charge $65-$85 dollars for simple office visits. Since most insurers do not pay for electronic consults physicians who provide such services are forced to either provide them for free or charge the patient directly. When insurers do pay for digital care they reimburse physicians only a fraction of a standard office visit. The predictable result- most patients choose to come to the office and pay a $20 co-payment instead of the full charges for an electronic visit, and most physicians choose to call a patient in to the office instead of providing discounted digital services.

What is overlooked by all is the hidden costs of the current system. If one takes into consideration travel and wait times, a 15 minute office visit can take 3-4 hours out of a patient’s work day. If the visit is done electronically, a 15 minute visit takes up only 15 minutes! For conditions such as the ones I described above, and for conversation based visits to treatconditions such as depression, migraines, hypertension and even diabetes there is often no reason for a patient to physically be in the office. The current system is incredibly wasteful.

As wasteful as it is change, if it is coming at all, is coming an incredibly slow pace. If the delivery of medical care is going to evolve it will require a concurrent evolution in the manner in which medical care is reimbursed. The traditional fee for service approach must change.

At present the best hope for change can be found in Health Maintenance Organizations which pay physicians monthly fees to care for the patients, regardless of setting. The HMO model, which is focused on outcomes, is more likely to be open to innovations in care delivery. Accountable Care Organizations, a new type of care delivery model that also focuses on outcomes, represent another possible source for promoting change. Even with new care models the impetus for change will ultimately come from patients. As more and more people become aware of the advantages digital care brings the demand is likely to increase.

Some may wonder, given the current state of affairs, how it is that I am able to provide digital care. I decided years ago that I wanted to be an innovator and to embrace change. Three years ago I began offering FaceTime and Skype visits to patients. I did so at no charge to HMO patients and at the price of my least expensive office visit to my fee for service patients. The response was initially slow but as co-payments have increased more and more patients are choosing the digital option for their care. For me, even though digital visits do not pay as much as standard office visits the personal rewards of knowing I am doing what is best for my patients has made it all worthwhile.

The future is coming, and I intend to be a part of it.

- Bart

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200 Blind Dates

Meeting new people makes me nervous. I have a big mouth and a strong personality, both of which can result in negative first impressions. Unfortunately for me my personal foibles carry over into my professional life. I am blessed to be liked by the majority of my patients but I at times struggle to make positive first impressions. There is so much that can go wrong the first time someone comes to the office.

I worry about wait times in the waiting room and in the office, about looking at the computer screen too long as I enter all of the patient’s health information, about addressing each and every concern, and about listening well and communicating clearly. I even worry about my appearance and grooming.

Each new patient interaction reminds me of how people must feel when they go on a blind date. You want to like the other person but find yourself analyzing everything about them while at the same time hoping not to make a fool of yourself. It is an incredibly stressful situation for a doctor who battles anxiety.

My anxiety has been in full force for the last few weeks. A local doctor in the community retired and my medical group transferred 200 patients into my practice. I find myself going on several medical “blind dates” each day. Most of the interactions have gone well (I think, no negative Yelp reviews- yet!) but there have been challenges. The retired physician seems to not have been completely up to date on all of his practices. Recommending changes in medications and treatment strategies to someone you have just met can be extremely delicate. I find myself exhausted at the end of each day.

I am certain it has not been easy for the patients either. It is not easy to put your health in the hands of a stranger. It is even more difficult when someone else picked the stranger on your behalf, when through no fault of your own you lost a physician you trusted. Some patients were transferred in the middle of care for serious problems and wondered if treatments would be delayed and if they would lose their specialists. These patients were understandably fearful.

In spite of the challenges and anxious moments these last few weeks have brought with them a valuable life lesson. I have been repeatedly reminded of the importance of communication, patience, grace and understanding. I have seen how taking a little more time and explaining a little more carefully can ease someone’s fears. I need to apply this in all of my social interactions. Kindness matters.

-          Bart

Words That Changed the World

2000 years ago on a hillside Northern Israel Jesus spoke words that turned religious thinking upside down. He spoke of humility and service, of weakness as the path to strength and of faith that came from the heart. Today we call His words The Sermon on the Mount. His teachings on that day are still radical and powerful.

Not too long ago I had the opportunity to teach on the most famous section of His sermon, The Beatitudes. Here is the first part of that series-

This is something new for me, as I have not uploaded videos to the blog before. Let me know your thoughts and comments! If, after watching the video, you are interested in having me come and speak to your church or community group, please contact me through the website. 

A Family Doctor Rant

I love my job and particularly enjoy taking care of my patients. Most of the time. Every once in a while I find myself in an unexpected debate with a patient over a straight forward issue. Some of these debates make me want to scream. In order to save my lungs and my sanity, I have decided to resolve some of the debates here.

1-Cholesterol medications are safe.

They have been prescribed for decades and have a long record of safety and effectiveness. They decrease heart attack risk by 20%. If you run into the patient I saw recently who was convinced that everyone who takes statins has complications and felt the need to argue this with me, tell him he is just plain wrong.

2-Colon cancer screening is the best cancer prevention test ever.

1 in 20 Americans get colon cancer. Less than 1 in 2000 people have a complication from colonoscopy. Sorry, patient who “had a friend” who told her the procedure was dangerous, but when you are 100 times more likely to be helped by a test than be hurt by it, you should get the test done.

3-Diabetes is a serious disease that needs serious attention.

Particularly for those individuals who are on insulin, consistent meals, in both timing and content, are a crucial part of managing the disease. Some of my patients with sky high blood sugars try to tell me that they can do it “their way”, but they are wrong. Winging it doesn’t work with diabetes.

4-The Physician/Patient relationship is a true partnership.

Good health care happens when patients and doctors work together. No, Mr. High Blood Pressure, you don’t get to take your blood pressure medications 3 months out of the year and expect to remain a patient in my practice! An essential truth about medications- they don't work if you leave them in the bottle!

5-“Feeling Good” and “Being Healthy” are not the same thing.

One might think, given all of the focus on prevention, that this truth was obvious. It isn’t. We have many patients who refuse to come in for follow up, refuse to get tests done and who haven’t had a check up in years. This is understandable when someone is 20 years-old but hard to accept when someone is 75. I had no choice but to accept it this week- a patient  hung up on me when I called to remind him!

I share these stories for two reasons. The first is to encourage people to not be one of these patients. Doctors do have the best interests of patients in mind and work hard to do a good job. It is incredibly frustrating to have to argue to get people to do the right thing. The second reason is to encourage a little grace when your doctor is grumpy. You never know what he may have been dealing with in the previous exam room!

Bart

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