Today I met a man who wanted to interview me before transferring his records. He was about my age and seemed polite and pleasant enough. He told me his doctor of a dozen years had started to taper him off his long-term narcotics after he reported some of them missing because of theft. He used to take the equivalent of about 1,200 mg of morphine per day for his back pain. ...

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Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the government and corporate America want them to have. Up until this point, the momentum has been with the payers, Medicare, and the insurance industry. But the more heavy-handed they become, the more inevitable the public backlash ...

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Every primary care physician has had this experience: We refer a patient to a cardiologist, pulmonologist or gastroenterologist and get a note back that says our patient’s symptoms are not cardiac, pulmonary or GI related. “Not my department,” in essence. Medical specialties are organized by organ or organ system, and not by symptom. This really leaves primary care doctors in the default role of being specialists in diagnostics. I often say ...

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Dear Santa, I’ve been a very good doctor all year. I have checked all my boxes and aced all my meaningful use requirements. This year, I’m not asking you for anything fancy. I just thought you might be able to instill some kindness and good will into the people who designed the user interface of my EMR. Maybe, with your help, they would come to see how a few minor tweaks ...

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The clues are usually there, even in the hardest of cases. They just aren’t presented to you on a silver platter. Gwen Stephenson had an ill-defined polyarthritis and had been on methotrexate for some time. Her rheumatologist, Norm Fahler, had tapered her off the medication while keeping an eye on her inflammatory markers and they had leveled off at just above the normal range. Seven or eight years ago, Gwen had suffered ...

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When a wife suddenly comes in for her husband’s appointment, I usually worry a little; when a husband shows up for his wife’s visit, I sometimes worry a lot. I have come to expect that when I enter an exam room, and a male patient has his wife with him in the room, she is there to make sure I hear some part of his symptom history that he has never ...

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Twenty years ago, I changed the name and focus of the annual physical I offered my patients. I designed a new form on my laptop with Geoworks, my favorite DOS-based (pre-Windows) desktop publishing program, and rolled out my “annual health review.” I explained to patients that many of the things we used to do in routine physicals every year had proven to be of little value, but there were more and ...

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From ancient times, doctors have appreciated that, for all their similarities, no two patients are exactly alike. This understanding is what made physicians act like, and earn society’s respect as, professionals. The commercialization of health care has brought in managers from other industries and other branches of academia, and their rise to power has been predicated on their ability to treat patients and doctors not as individuals, but as small cogs ...

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A long, long time ago, hospitals existed to admit patients when they were sick, treat them with medicines or surgery and good nursing care, and discharge them after they became well. Hospital care was at one time a charity, which evolved into a nonprofit service, before it became a very big business. In olden days, nonprofit hospitals charged patients straightforward fees for their services. Then, when you were just a young whippersnapper ...

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Theresa arrived in a cloud of noise and commotion. She had called after four o’clock the day before, but I hadn’t noticed the new message in my electronic inbox before I left the clinic. Her almost brand new alprazolam bottle and her pain pills were missing, and Theresa was reeling. As she walked down the hall to the exam room, I heard her explain to Autumn how she had been to Walmart ...

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