Recording patient/doctor encounters: A modest proposal

This is a guest post by Dr. Drake Ramoray (A pseudonym. He is not affiliated with the actor, character, the show “Days of Our Lives,” or NBC.)

I have been assured by a very knowing American of my acquaintance in London, that a young healthy child well nursed is at a year old a most delicious, nourishing, and wholesome food, whether stewed, roasted, baked, or boiled ...—Jonathan Swift

I have A Modest Proposal. I suggest we just videotape all patient/physician encounters. Why rely on a possibly low quality audio recording where exterior noises or interruptions could interfere with the quality? Furthermore, perhaps my comment that may or not be taken out of context will make more sense if one can see my body language. Even better, lets just transmit the videos directly to CMS and your insurance carrier so we can add additional layers of bureaucracy and non-medical personnel to the mix whose pay has to come out of physician charges, taxes, or patients' premiums.

Does talking about burnout cause more burnout?

Almost every day over the last few years, someone has written about physician burnout or depression.

The problems begin in medical school. A recent paper featured drawings that medical students had done depicting faculty as monsters. One student felt so intimidated during a teaching session that she drew a picture of her urinating herself.

The paper equated faculty and residents supervising students to “zombies, vampires, ghosts, and other supernatural figures.” In dealing with the state of the world today, the authors cited a comment by the novelist Stephen King saying that to cope with adversity, people make up horror stories. That sounds pretty serious.

Could the problem be declining student resilience? An article about college students in Psychology Today pointed out that they are less able to deal with seemingly minor affronts. And teachers are reluctant to “give low grades for poor performance, because of the subsequent emotional crises they would have to deal with in their offices.”

This has forced faculty “do more handholding, lower their academic standards, and not challenge students too much.” The article pointed out that college students exhibit more anxiety and depression and take more prescription drugs for these problems than ever before.

It’s not just students.

A systematic review of 54 studies found that 29% of resident physicians were depressed or had depressive symptoms. The number ranged from 20.9% to 43.2%, depending on the method studies used to assess depression.

Investigators from the Mayo Clinic and the AMA found that more than 50% of practicing physicians surveyed exhibit symptoms of burnout, and the problem has worsened since 2011. Depression and suicidal thoughts are also common.

All of these studies have been covered extensively by media such as the Washington Post, NPR, Time Magazine, Forbes, among many others and were widely discussed on Twitter.

Here’s a thought. What about “emotional contagion,” the subject of a 2014 paper published in PNAS? The authors studied 689,000 Facebook users and found that negative emotions can be transferred from one person to another without direct contact. They concluded, “…emotions expressed by others on Facebook influence our own emotions, constituting experimental evidence for massive-scale contagion via social networks.” If emotional contagion has such an impact on Facebook users, maybe all these stories about burnout and depression have an impact on students and doctors too.

There is certainly much to be depressed about in medicine—stress, declining reimbursements, soul-sucking electronic medical records, long hours, arbitrary rules, and much more.

Could it be that the more stories written about burnout and depression, the more burned out and depressed doctors become?

Patients vs. doctors

A JAMA Viewpoint article suggests that doctors should be aware that patients may be surreptitiously recording their conversations. The author, a neurosurgeon, takes a very benign view of this issue and recommends that if a doctor suspects that patient is recording a conversation, "the physician can express assent, note constructive uses of such recordings, and educate the patient about the privacy rights of other patients so as to avoid any violations."

He also says this would show that the physician was open and strengthen the relationship between the doctor and the patient. I'm not so sure.

Here's a different perspective. If a patient is secretly recording a conversation, the relationship between him and the doctor is already in serious trouble. What I would do is to tell that patient to find another doctor.

If a patient asked me if it was OK to record our conversation, I would agree, but I would also want to record it to preserve a complete copy.

This comes on the heels of another privacy and trust question—should doctors google their patients? There is no consensus on this, but having read several discussions on the topic, most writers feel that googling patients should only be done for certain narrow reasons which you can read here.

Most medical societies have not weighed in on the subject, but I would guess when guidelines are published, they will discourage the practice. But of course, patients may google physicians at will.

Taking it to another level, Dr. Jeremy Brown, Director of the Office of Emergency Care Research at the National Institutes of Health, recently proposed that emergency physicians should be equipped with body cameras to record audio and video of patient encounters.

Leaving aside such questions as who owns the videos, how to store the vast amount of data, and what impact this would have on the performance of the individual physicians, body cameras would establish an adversarial relationship that is unnecessary for the overwhelming majority of doctors and patients.

A physician interaction with a patient begins on terms quite different from those of a police officer interacting with a suspect in which the adversarial relationship is already established. The increasing number of controversial and highly publicized cases involving police and suspects has resulted in a need to protect both parties. This need seems much less pressing in medicine.

Where does this end? Should all patients be equipped with body cameras too in case the physician copy "gets lost"?

It is sad to realize how far we have sunk as a profession.

Do surgeons still do postop care?

Here's an email I received the other day (edited and posted with the author's permission):

I am a recently retired internist. I have noticed some evolving trends over time and had an interesting experience that illustrates this issue.

A 77-year-old friend went for check up due to urinary incontinence. He was found to have a large prostate and a PSA of only 2 so was given Flomax . This helped somewhat.

At the time, an asymptomatic hernia was found. He was immediately scheduled for surgery which went well. His Foley was removed, and he was sent home.

At home he could not void, called the surgeon, and was told to go to the ER, There the Foley was replaced, and he was to see his urologist in 2 days. The urologist removed the Foley. Later he was in agony and walked the floor all night. He called the urologist and the service said that the office was closed. He was told to drive to the other office in the next town only 15 miles away. They replaced his Foley again.

Doctors should be more like…

A while ago, Atul Gawande, the noted surgeon-author, wrote a long piece in the New Yorker on why healthcare should look to a restaurant called the Cheesecake Factory for some guidance on how to standardize things.

This was met with some derision by a number of physicians who pointed out, among other things, that the food at the Cheesecake Factory is not great and is loaded with calories. But I guess it's at least it’s "standardized" mediocre and unhealthy food.

Then a doctor named Peter Ubel wrote in Forbes magazine that doctors should take a cue from Starbucks about how to deal with people. He went so far as to say that baristas have more emotional intelligence than physicians.

He says the Starbucks staff are trained to placate angry customers using the mnemonic “LATTE,” which stands for “Listen to the customer, Acknowledge their complaint, Take action by solving the problem, Thank them, and then Explain why the problem occurred.”

I have never worked at Starbucks, but when I was a surgical chairman, I unknowingly used most of their principles in dealing with patient complaints about my attending and resident staffs. I could add another. I used to ask the dissatisfied patients and families "What can I do to make you happy?"

I was surprised that in many cases, the complainants could not think of a single thing that would make them happy. The question often completely diffused the confrontational nature of the encounter. You might want to try it sometime.

Another way of looking at this issue was suggested by a Twitter colleague, Dr. Edward J. Schloss, who tweeted that we work for the government, and we should be compared to the Bureau of Motor Vehicles or the post office, not Starbucks.

Since doctors are already notorious for making people wait, comparisons to the BMV would seem appropriate. And some docs also take forever to return phone calls, similar to the post office's habit of delaying the mail.

Surely physicians look better when compared to another government agency, the Internal Revenue Service, especially now that the IRS has been accused of selectively harassing certain political groups and spend lavish amounts of money on conferences.

At least no one has suggested comparing us to pilots lately. I have dealt with that analogy decisively in the past here.

Why should practicing medicine be compared to any other occupation?

Doctors are unique. None of us is perfect, but despite the occasional bad apple, most of us are doing the best we can for our patients under difficult circumstances.

Universal medical licensing for doctors—a good idea that will never happen

Some well-intentioned people at the Center for American Progress say that the concept of individual state medical licenses is outdated, and states should recognize each others' licenses.

On the Health Affairs Blog, they listed many convincing reasons for this plan such as the streamlining of some requirements—many of which are unique to each state, the consolidation of such things as background checks and paperwork, decreasing costs to physicians, the fact that individual licensing has hindered the development of telemedicine, difficulty in credentialing physicians trying to help out in disasters, delays at best averaging 2 to 3 months to obtain a license in another state, and others.

On Twitter the idea was endorsed by Dr. Ashish K. Jha, a health policy researcher at Harvard. However, he wondered whether state boards would tolerate the loss of income. To me, the answer is simple. No.

To give you an idea of the magnitude of income the states receive, consider these figures.

According to the Federation of State Medical Boards (FSMB) as of 2012, there are approximately 878,000 MDs and DOs with active licenses in the United States. This includes 142,423 (16.8%) who have active licenses in two states, and 50,454 (5.9%) with licenses in three.

The average cost of a medical license and yearly renewal in each state is about $400. I was unable to determine exactly how many states require yearly renewal, but a spot check suggests that it is well over half.

I'll do the math. Using the FSMB data, there are about 192,000 doctors with active licenses in two or three states. If states recognized valid licenses from other states, they would lose about $100,000,000 in yearly revenue. (142,423 docs would no longer have to pay for one additional license and 50,454 for two additional licenses [50,454 x 2] x $400.) And to yield all medical licensing to the feds, the states would lose another $351,200,000 (878,000 x $400) every year.

The state medical boards probably couldn't even make the decision independently. Another figure which I could not obtain is how many states funnel medical licensing income into their general funds instead of using the money to investigate complaints about doctors. I know some states do so for sure, including Connecticut and Texas.

It seems many of these fees are really taxes disguised as licensing costs.

Yes, universal medical licensing is a great idea, but the states will never give up this money.

Annoying things about medical reporting

1. An article in Time magazine is headlined "It's Not You, Doctors Are Just Rude."

The first sentence of the article is " Doctors-in-training are in need of a dose of compassion."

It describes a paper from Johns Hopkins and the University of Maryland about intern communication behaviors. Interns were watched by trained observers.

Although interns were pretty good about touching patients and asking open-ended questions, they only introduce themselves 40% of the time and explained their roles only 37% of the time. They also sat down with patients just 9% the time.

Observations were made on 732 patient encounters, but only 29 first-year internal medicine trainees were involved.

The abstract did not explain whether these first-year interns had received any training in communication ("interpersonal skills and communication" is one of the 6 ACGMA core competencies), nor did it state at what point in their first year the study was done.

The headline of the piece in Time is a bit misleading since it suggests that all doctors are rude. Similarly, the first sentence of the article somehow brings in compassion.

The study was not about rudeness or compassion; rather it was about communication.

Maybe Johns Hopkins and the University of Maryland need to do a better job of teaching its interns, and maybe Time magazine needs to do a better job of reporting.

2. An article from a website called iMedicalApps gushes with excitement about the fact that Google Glass can be used by a surgeon to view continuous vital signs while operating.

It could be that Google Glass is going to revolutionize medical care, but I don't think it's going to be useful in the context of a surgeon looking at vital signs while she is operating.

You cannot concentrate on the operation and look at a Google Glass display of vital signs.

When I was operating, I was fully focused on the procedure. I depended on the anesthesiologist to alert me to any significant changes in the patient's vital signs.

If I wanted to know what the vital signs were, I simply asked the anesthesiologist. For me, that low-tech action was adequate.

3. Here's a headline from the Los Angeles Times. "Walk this way: Men slow down when sex is at stake."

This one is about a study from PLOS One that looked at 11 male and 11 female college students who walked around a track alone, with a significant other or with friends of the same or opposite sex. The study found that men walked significantly more slowly when they were paired with a female romantic partner compared to walking with another man or a woman who was simply a friend.

The authors concluded following: "Because the male carries the energetic burden by adjusting his pace (slowing down 7%), the female is spared the potentially increased caloric cost required to walk together."

This finding supports the idea that men are helping their romantic partners conserve energy and thus promote reproductive success. This is apparently a big issue in hunter-gatherer societies who walk long distances. It's not quite so clear why college students walking 400 meters would do the same thing. The authors speculated that it might be an evolutionary issue.

Regarding the article, a woman who follows me on Twitter said, "Not my hubby, tho we do have 2 kids."

Sorry LA Times, this one's not about sex, but I guess it makes for a better headline.

Can retired specialists be retrained to ease the shortage of family doctors? No

Last week there was some buzz on Twitter about a proposal from a retired plastic surgeon in San Diego who has developed a plan to retrain retired specialists as family practitioners. The idea is that this could alleviate the shortage of primary care physicians that exists now and is predicted to worsen as more people become insured.

The 15-module course created by some faculty at the University of California at San Diego involves 100 hours of online study with patient simulator testing on the campus for tuition of $7,500.

According to an article in U-T San Diego, at least one doctor, also a retired plastic surgeon, has completed the course and seven more have enrolled.

Is this a possible answer to the shortage of primary care physicians?

I think not.

Take the course—100 hours of online learning. Does that sound like enough to you? It takes three-years to complete a family medicine residency. Most plastic surgeons I know haven't touched a stethoscope since medical school, don't know the names of any drugs, and couldn't recognize a sick patient under any circumstances.

I rarely look at the comments for online articles, but I read a few family medicine physicians' comments on this. They were highly indignant at the mere mention of training anyone to do what they do for only 100 hours. I would have to agree.

As one commenter said, there must be quite a few lawyers in California salivating over this scheme. Maybe it was even cooked up by a committee of the plaintiffs' bar.

Another small flaw in this plan is just how many retired specialists would even want to do this?

With all due respect [this is what someone usually says to preface a disrespectful comment], I couldn't do it.

We all considered primary care when we were in medical school, but we did not do so for one reason or another. I'm glad some people did. Bless their hearts.

For me to become a family practitioner at this or any other stage of my life would be tantamount to going straight to hell without passing "Go" and without collecting $200.00.

The primary care shortage is going to have to be solved without me and, I suspect, most of my specialist colleagues.

Anger management for doctors

A recent Washington Post/Kaiser Health News story about anger management led with an anecdote about a surgeon who broke a scrub tech's finger by slamming down an improperly loaded instrument. The surgeon was suspended for two weeks and had to take an anger management course, which seems like a mighty small penalty for what could be described as assault.

But the story had to go where many such tales seem to go these days.

Here's a quote: "Experts estimate that 3 to 5 percent of physicians engage in such behavior, berating nurses who call them in the middle of the night about a patient, flinging scalpels at trainees who aren't moving fast enough, demeaning co-workers they consider incompetent or cutting off patients who ask a lot of questions."

Demeaning co-workers and berating nurses who call in the middle of the night? Yes, these things unfortunately do occur. But "flinging scalpels at trainees"? Sorry, I don't think so. But of course, exaggeration is a common feature of articles about doctors, especially if the story wants to portray us in a negative way.

I was a surgical chairman for many years. I know all about disruptive doctors. In a recent blog, I even admitted to throwing an instrument myself once when I was a young and headstrong resident.

A link in the Washington Post story goes to a full text paper on disruptive behavior in the Journal of Medical Regulation (who knew there was such a journal?). The author points out that isolated episodes of what some might consider bad behavior can happen, but unless there is a pattern or the incident was egregious, doctors should not be labeled as disruptive.

There are many problems with disciplining disruptive physicians. The article addressed a few of them. 

Here are a couple that weren't mentioned. 

The disruptive doctor may be a busy surgeon or big admitter of patients. This puts the hospital in a bind, especially if there are other hospitals nearby. The doctor can and will threaten to take his patients across town. 

Or the bad actor may be the only physician in a critically important specialty on staff. 

These situations give physician miscreants leverage which tends to mitigate the punishment meted out—analogous to the way pampered athletes and movie stars are treated when they commit crimes.

I have first-hand experience with this having dealt with disruptive surgeons in the past. What I wanted to do and what the hospital administration would permit me to do weren't always the same. By the way, behavior modification programs rarely result in permanent cures. A middle-aged surgical ogre is not likely to become Prince Charming after two weeks of anger management.

So the issue is not as straightforward as it seems. 

By the way, just to show how far toward equality we have come, that surgeon who broke the scrub tech's finger was a woman.