Zoe's first podcast

Live (barely) from Vancouver

I'm at a conference in Vancouver, BC the first part of this week on redesigning the clinical office practice. There was a time in my life, not too long ago, when if you'd told me I'd be at this conference, I'd have responded unpleasantly. But this is actually really fun for me.

Brooke and I had planned a fun weekend in Vancouver with the girls in advance of the conference. Brooke got a great deal on a one-bedroom suite at the Sutton Inn in busy downtown Vancouver, and we made plans to play outside in Stanley Park and visit the aquarium. Brooke got sick with a very painful sinus infection, and was pretty miserable, but we figured she might feel better, and if she didn't she could sleep while the girls and I played.

She did not feel better.

And then Zoe did not feel well. The poor child came down with a 103-degree fever on Saturday and was knocked out. She had about as much energy as a wet noodle. She was only a little low in the morning, so we (minus Brooke) made it to the park to ride the train and visit the petting zoo, but she clearly was just going through the motions. By afternoon (tipoff time for the Huskies second round loss), she was noodle-like, flat out on the couch. Brooke pretended to feel better and took Elliott out for a while, because she was neither ill nor lacking in energy.

By Saturday evening, we were kind of down (not Elliott), feeling like the weekend was a bust, and worried about Zoe.

Sunday rolled around and Zoe's fever broke, and we rejoiced briefly until she began puking. After some debate, we decided that I would accompany us all back to Seattle and drive back up to Vancouver later in the day, in time for the conference. This was fine with me, because I love road trips. By the time we got home, Brooke was better, Zoe was improving, and Elliott was still Elliott, but slightly unstable due to lack of nap--so, high energy, stroppy, and unpredictable.

And I had a little cough, but I deemed it a sympathy cough, so I drove back to Vancouver. At the border, I wondered if they had any way of knowing that I'd crossed three times in four days and how would I explain that without a long story. Knowing what I think I know about complex systems, it seemed unlikely they would know or care. It wasn't a problem.

But my car developed a sympathy cough. As I sat in line, the engine began to sputter and lurch. I don't know the first thing about cars, but I decided this must be some simple obstruction, like a kidney stone, and that it would pass. But I am stupid and prone to denial about things I don't understand, and my Honda pointed this out to me with a flashing "check engine" light.

And I wondered, as I sputtered forward in line ten feet at at time, if your car dies in that limbo between countries at the Peace Arch border crossing, what happens? Is there some intergovernmental towing authority to rescue you? Do they take visa or honor my AAA card? And how would I alert anyone without making a seemingly hostile pedestrian approach on the Canadian border?

Fortunately, this did not come to pass. I sputtered through customs uneventfully, and decided I would just drive until something bad happened. The check engine light became un-illuminated, and the sputtering became less pronounced, but did not stop. I arrived at my hotel in downtown Vancouver, left the shuddering hunk of metal with the valet to be parked and rest and overcome it's affliction.

Sometimes denial gets you where you need to go.

So the car has been convalescing in the garage and I have been walking in the rain between my hotel and the conference center and the pharmacy, where I've stocked up on NyQuil and DayQuil to aid in my own convalescence. I spent last night with fevers and chills and a painful cough, and today pretending I was fine while learning about LEAN approaches to primary care clinic transformation. And enjoying it. Really.

Though I did forget my coat. And it is both cold and wet.

And windy.

Tomorrow I will attemp to drive from Vancouver to Seattle in a car in need of service, in some stage of viral suffering, under the unpredictable influence of sinus decongestants and caffeine, and without much reliable cell phone coverage.

And I'm just certain it will be fine.

Leading like a child

I had the opportunity recently to attend a three day class in facilitative leadership, and it has re-shaped the way I think about almost everything I do. And really what it was...was...kind of a review of kindergarden, but with grown up examples from work. Very cool.

The basic idea was that we get things done--our work--through other people, and so it's probably a good idea if we all have some shared understanding of our work, even better if we all feel like we got to say how we think we should do it, and we would all like to hear that we did a great job.

In my daughter Zoe's pre-kindergarden class, the curriculum is the same. But Zoe comes home with art, and rocks in her pockets.

In the past few weeks, I have re-approached my responsibilities in at work with my new AP-kindergarden skills. In clinic, we created a vision--together--of what makes a good day. A really good list of about twenty things. Share, help each other, smile...a lot of these things are very basic, but in the chaos of a primary care clinic, they can get lost.

We also have identified things that get in the way of having a good day every day, and I've made it my job to guide us through ways to overcome those obstacles.

For every problem, we look at everyone who is affected (the stakeholders) and might want a say in creating a solution. We consider what a good solution would look like for them (a win). And we create the simplest possible plan we can all agree on.

So far, so good. I've been going for the easy "wins" first. There are bigger obstacles to having a good day every day, but we'll find our way. Together. Kindergarden-style.

Rambling Ambition

It's six o'clock in the morning. I've spent my morning "quiet time" working on a meeting agenda and not writing, as I'd hoped. I'm going to try to squeeze this in, though when Brooke's hairdryer goes on, that's my signal to sign off and move upstairs. Squeezing things in is how things have been, lately. Everything is manageable, but there is never quite enough time to do EVERYTHING I'd like to do. I've been learning a lot in most areas of my life: medicine, family, leading others, being efficient. But I think I trip over my ambitions. I want to be an excellent doctor, a competent leader, a thoughtful, patient, and present father and partner, and I want to do it all effortlessly.

Ha.

And I'd like to be in better physical shape at 40 than I was at 30.

The hairdryer is going.

I've been working a lot recently with methods for clarifying just what all those ambitions actually mean to me. What would it look like if I achieved all those goals? How can I plot a course from here to there? Am I already there in some respects? Is it really important to fret about it?

Am I trying to hard? As Yoda says: "There is no try, only do."

Is it wrong to look to a muppet for guidance?

I like my doctor, but the tart was a little dry

This morning's New York Times has a nice opinion piece about publishing patient ratings of doctors. The editorial board likes it. I like it. Patients like it. Who doesn't like it?

Doctors with low ratings, I suppose. (Note, that could be me; I've never seen patient ratings of me or my clinic.)

Note that the questions used in the Zagat/WellPoint ratings (yes, Zagat) appear to be built, at least in part, around validated patient experience questions from Gordon Moore's research. From the NYT:

Who knows better than patients whether they have confidence in a doctor? Whether they like his or her bedside manner? Or find it easy or hard to make appointments? Or are dealt with on time or kept waiting for hours? Or find the staff helpful? These are the kinds of items covered in the Zagat/WellPoint survey, not anything to do with the quality of medical care provided.

These are similar to Moore's patient experience questions:

1. I have one person I think of as my personal doctor or nurse
2. It is very easy for me to get medical care when I need it
3. Most of the time, when I visit my doctor’s office, it is well-organized, efficient, and does not waste my time
4. The information given to me about health problems is very good
5. I am confident that I can manage and control most of my health problems
6. I feel able to give meaningful feedback to my doctor’s office about ways things could be improved

Wouldn't you feel like you were being well-served as a patient if you could answer yes (enthusiastically) to these questions?

As a physician, I have an obligation to provide the highest-quality medical advice, supported by science. I also have to be a good practicing colleage to other physicians and staff who need my work to be thorough, clear, and timely.

But I also have to keep in mind the perspective of my patients, what they want and need. Doing a good job for them also means responding to the issues surfaced in the Zagat/WellPoint and Moore patient experience items.

It doesn't mean patients will always agree with my recommendations, or that I'll agree with their assessments and requests, if science and common sense suggest otherwise. But the experience ought to be efficient, respectful, and thorough.

I'm glad someone is measuring. Maybe I could be, like, the Nobu of family doctors one day.

Twittering the Future of Family Medicine?

I had the chance last night to meet with some amazing family doctors to discuss ways to use social media to open and sustain a discussion about the current state of primary care and where we're going. And where we should be going. And how.

There will be room for every voice and perspective about how to get from where where we are now to someplace (or places) better for patients, public health, and the well-being of those who deliver primary care.

Primary care is stressed:

• Access is poor: the uninsured don't have access, and if everyone did have insurance, we wouldn't have enough primary care doctors to care for them;
• Costs are out of control, and we don't get much health for our health care dollars;
  
• Reform at the federal level isn't as near as maybe we'd all thought. The white knight of bipartisan reform, Tom Daschle, got knocked out with an IRS body blow. And getting a big deal done on health care seems unlikely, even if it is even more important now than ever.

So what to do? There is tremendous support, in spirit, for better primary care, and it seems now that everyone wants a "Medical Home," though no one can agree on what that means, and the average primary care private practice can't afford to build one.

At out discussion last night, we agreed that there are things family doctors can do right now to move primary care forward at the front lines of practice. And we'll talk about those things in the online forum we're building. We'll blog, podcast, photograph, and discuss the path from here to somewhere better. And we'll make it practical. There's enough rhetoric already.

My assignment: name the project. Eep.

I'm on it.

Stress-free primary care?

When I graduated from medical school in 2005, my friend Liz gave me a label maker and a book called Getting Things Done (GTD). I assumed it was a gag gift, though I knew Liz to be a fan of GTD and its author, David Allen, a productivity swami. I thought it was interesting, so I read it.

And then I labeled everything.

Over the last few years, I have practiced a watered-down version of the GTD process, which advocates "stress free productivity" through effective management of the information that comes to us faster and faster. When the mind is unburdened of the task of remembering all the things there are to do, it is possible to be present for whatever task is at hand.

Through residency, this was tough. The task at hand generally involved some high-stakes activity performed in the setting of sleep deprivation and incompetence-by-design. Delivering babies, for example: you become competent by doing it, they come in the middle of the night, and it's a big deal if you screw it up. There was little about residency that allowed for stress free productivity. I did what I could, but there were limits. Mostly, I just crashed through.

I've been out of residency less than a year, and have been a full time family doctor for a little over six months. I work five full days in clinic, seeing about eighteen patients a day for multiple concerns, acute and chronic. I also manage dozens of lab and study results every day, and respond to patient phone calls and email.

My goal: go in every morning relaxed and prepared for whatever comes my way and leave at the end of the day having acted on every piece of information that came my way. That doesn't meet I've cured everybody, cure is pretty rare in medicine.

But hope that by day's end I will have responded to every item that demanded my attention in a appropriate way:

• Every patient visit ends with a mutually agreed plan;
• Every patient call that came in got an answer, a plan;
• I reviewed every lab or study result and made a plan;
• I updated patient charts to clearly describe the plan to everyone who might need to know.
• I set up reminders to myself so I don't worry that I'll forget about important parts of the plan.
  

When I accomplish all those things, there is an empty in-box in front of me, ready to receive whatever might arrive next.

More importantly, my head is not cluttered with all the things I "should" be doing or trying to remember all the things that might be coming in. Unburdened, I feel much more able to be fully present for patients during the twenty minutes I get with them. We have a lot to do in those brief visits and they expect my full attention. When I'm on my game, they get it.

Maybe I'll write more about this later. It seems like a good topic to explore further (running a visit, how the day flows, setting reminders, updating care plans, teamwork and communication, cross-covering for colleagues...)

But it's time to get started with the day, so off I go.

A path of endless bickering

The health care reform effort won't get far if doctors whine like toddlers instead of being realistic about the need for payment change. An article in the recent American Academy of Family Physicians NewsNow newsletter online began like this:

A recent editorial by AMA Board of Trustees Chair Joseph Heyman, M.D., has led AAFP President Ted Epperly, M.D., of Boise, Idaho, to emphasize the importance of the AMA working with primary care physicians to ensure they are fairly and adequately paid for the services they provide to patients with Medicare coverage.

Heyman's editorial, which was posted Jan. 26 to American Medical News online and published in the Feb. 2 print version of the publication, urges payment increases for primary care physicians, but he emphasizes that the AMA would not support such increases if it means there would be corresponding reductions in subspecialists' payments.

"Payments to primary care physicians must increase," said Heyman, an OB-Gyn. However, he added, the AMA "absolutely opposes applying budget-neutrality rules that confine offsets to the physician payment pool."

"Congress should not rob Dr. Peter, the surgeon, to pay Dr. Paul, the primary care physician," said Heyman.

So, if primary care doctors earn more (encouraging more medical students go into primary care to fill the gap), and the specialists still get paid a lot to do procedures that may or may not be helpful to patients' health, then were does the savings come from?

We know that a good primary care system saves money by decreasing complications of chronic disease, so there's an argument to be made there, but I think we should act less like children fighting over who gets more M&Ms (or BMWs), and frame the debate around questions that matter.

Doctors should get paid for delivering care that works. The payment system we have rewards procedures and discourages talking to patients. Not everyone needs a colonoscopy to look for colon cancer (very few people do, actually), but we put a lot of cameras into a lot of bottoms for a lot of money when a $10 screening study you can do at home is equally effective at preventing colon cancer mortality.

As the Dartmouth Atlas of Health Care points out, where there are specialists, there are is more specialty care. Live in a town with lots of gastroenterologists? Predict lots of colonoscopies. It has nothing to do with evidence or effectiveness. Doctors have to pay the bills like everyone else, so you do what you're trained to do and bill accordingly.

I agree that physicians should be paid fairly for the work they do, procedure or not. But we should only be paid for care that works (i.e. has a measurably positive effect in patients' lives). Elective colonoscopy for colon cancer screening? Medicare shouldn't pay for that (or should pay $10, which is what it costs to screen for colon cancer). Eventually the payments to specialists would be driven down using good outcomes-oriented science, fewer medical students choose lucrative lifestyle specialities.

Reframe the debate around what matters, what works, instead of bickering about cost neutrality. Health care costs too much. Some of us have to get less in order to make it work. And we'll all do just fine. Maybe our patients will, too.

Plan B?

"There was no Plan B." So said David Axelrod yesterday following the abrupt end of Tom Daschle's bid to be the white knight of our failing health care system.

I think Daschle did the right thing in bowing out. It was the first right and non-stupid thing he did in a little while. I'm not sure how on earth someone avoids more in taxes than most people earn in in salary and thinks it won't get in the way of a senate confirmation. I also don't understand why taking $5 million in fees from the health care industry (my people, admitted) and thinks that won't come up as a legitimate conflict.

But we're all in agreement now, right? Daschle acknowledges the problem and dropped out. Obama acknowledges the mistake in allowing it to go this far, which created what even the most love-struck Obamanite would agree is an inconsistent rule: no lobbyists or murky ethics in the new administration, except when it suits the administration's needs. I feel better knowing that people in DC can do the right thing, even when it screws up the plan.

And as for the plan--meaningful improvement of how we deliver health care in America? Well, according to David Axelrod, Daschle was it. "There was no plan B."

Super. I'll be Congress will have a plan B, and it won't include universal coverage, guaranteed primary care services (prevention and chronic disease management), nor any kind of incentives for more students to enter primary care.

We've arrived at the time we've been talking about, when our health care system is unsustainable. Companies can't afford to keep the lights on, much less pay huge health care premiums for employees. Employees lose benefits or just lose their jobs. Patients come to me asking for six months of medications because they're losing coverage, and ask for hard copies of their scripts to take to WalMart for the $4 medication plan instead of filling for a few dollars more at our clinic pharmacy.

And there is no plan.

Having the federal government cover 30% of COBRA costs for out of work families is kind of like giving them a buck to help with the rent. Not enough. Out of work is out of work, zero income doesn't cover 70% of a health care premium.

That's not a plan.

There will be some kind of change, but I worry it won't actually help anyone. Those who spend a good part of the year shelling out cash while they wander around in the Medicare Part D donut hole understand meaningless change.

Let's hope for a good, solid plan B, and fast.

And by the way, Mr. President, good for you for admitting your mistake. I expect the learning curve in your job is steep. If you learn from the mistakes, we'll all benefit.

Hope lives on.