I scribbled my signature on a pharmaceutical rep’s iPad today for some samples of Jardiance, a diabetes drug that now has expanded indications, according to the Food and Drug Administration. This drug lowers blood sugar (reduces HbA1c by less than 1 point) but also reduces diabetes-related kidney damage, heart attacks, strokes and now also admission rates for heart failure (from 4.1% to 2.7% if I remember correctly – a significant ...

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So many primary care patients have several multifaceted problems these days, and the more or less unspoken expectation is that we must touch on everything in every visit. I often do the opposite. It’s not that I don’t pack a lot into each visit. I do, but I tend to go deep on one topic, instead of just a few minutes or maybe even moments each on weight, blood sugar, blood ...

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Doctors need to be true to themselves, but at the same time, they must be chameleons. A doctor fills certain roles in the lives and stories of patients. It is a two-way relationship that looks different to each person we serve throughout every workday and even in the most casual interactions we have. Some patients need us to take charge for a while because they’re exhausted; others need us to listen quietly ...

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The family doctor used to be almost the only source of medical information patients had access to. Now, few people need us to bring them the latest news. It’s there for everyone to see. There’s even too much of it. Today, our role is to help make sense of it all. In order to do that, we must possess and project authority, but we have no reason to put ourselves on ...

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In most other human activities, there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Health care spans from one extreme to the other. Think code blue versus diabetes care. Primary care was once a place where you treated things like earaches and unexplained weight loss in appointments of different lengths with documentation of different complexity. By doing both in the same clinic over the lifespan ...

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I have advocated before for putting a visit synopsis at the beginning of each visit note. I have called that the aSOAP note. I think that works immensely better than APSO notes that only rearrange the order of the elements. The reason I say that is that in today’s EMR notes, it’s too darn hard to find the story. If a note is half a dozen pages or ...

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The answer to physician burnout is purported to be resilience training. That’s like glorifying the natural ability of frogs to tolerate gradually heating and boiling water. Unfortunately, health care today has some toxic ingredients, and physician burnout is directly related to them. Some forms of resilience training I have been exposed to are no more than mental escapes away from medicine, such as art, music, and personal relationships. Those types of activities ...

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The receptionist interrupted me in the middle of my dictation. “There’s a woman and her husband at the front desk. She’s already been seen by Dr. Kim for chest pain, but refuses to leave, and her husband seems really agitated. They’re demanding to speak with you.” I didn’t take the time to look up the woman’s chart. This could be a medical emergency, I figured. Something may have developed in just the ...

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Touch is a sensitive thing. No pun is intended here, but whether and how we touch our patients deserves our careful thought and deliberation. So much interpersonal contact these days is virtual, with emojis, abbreviations and whole words thrown around as substitutes for human contact. Think XOXO and, “hugs and kisses.” And when people do touch in our health care environment, it is often with gloves, even for simple fingerstick blood ...

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There are two versions of “the conversation” we have with men: One is for teenage boys, and it is about wet dreams, sexually transmitted disease, unwanted pregnancy and at one point also about testicular self-examinations. Those have now been edited out of the script, which makes sense to me since I have seen only three cases of that in forty years of practice, all but a couple of them diligently ...

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It wasn’t even nine o’clock when the screen on my laptop suddenly froze. From that moment until my last patient left the building, my clinic had no internet. For my part, the day went pretty smoothly, mostly because of some of my own work habits. It also helped that it was a warm, sunny day, and my schedule was on the light side. Others have frowned at my old-fashioned work habits, ...

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It’s a funny world we live in. Lots of people make a handsome living, defining their work and setting their own fees and hours with little or no formal education or certification There are personal and executive coaches, wealth advisers, marketing experts, closet organizers, and all kinds of people offering to help us run our lives. In each of these fields, the expectation is that the provider of such services has his ...

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In business literature, I have seen the phrase “getting paid for who you are instead of what you do.” This implies that some people bring value because of the depth of their knowledge and their appreciation of all the nuances in their field, the authority with which they render their opinion or because of their ability to influence others. This is the antithesis of commoditization. Many industries have become less commoditized ...

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Some drugs are used for indications beyond their original FDA approved ones that make complete sense. I mean, if old seizure medications help nerve pain, it might be reasonable to try new ones for the same purpose if everything else fails. Sometimes the broader use of a medication leads to additional FDA approved indications. One good example is bupropion, Wellbutrin, for smoking cessation. It even got a new name for that indication, Zyban, ...

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My first job after residency was in a small mill town in central Maine. I joined two fifty something family doctors, one of whom was the son of the former town doctor. I felt like I was Dr. Kiley on Marcus Welby, MD. I didn't have a motorcycle, but I did have a snazzy SAAB 900. Will was a John Deere man, wore a flannel shirt and listened to A Prairie Home ...

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I keep thinking about the dichotomy between covering a lot of ground and getting to the point. The other day I saw my bosses at one of my clinics stop in their tracks when I suggested that a lot of the things we are measured on as physicians could be turned into standing orders and simply get shifted off my plate. I have just created a letter that anybody can send ...

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I’ve known Pat McCann (identifying information changed) for many years. He carries a diagnosis of COPD and has a preventative and a rescue inhaler, but he has never really had any serious flare-ups. He fell and broke his hip. Then he went to skilled rehab, one of a half dozen near Cityside Hospital. His stay turned longer than expected because he fell, luckily didn’t break anything, but had to go back ...

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Most Saturdays, I join a therapy session down the hall from where I do my walk-in clinic. A patient of mine has a weekly session just before the Alcoholics Anonymous meeting at noon in our big conference room. Last weekend he told my behavioral health colleague that the people in the AA group who have the most solid recovery seemed to be the ones who claimed to carry a lot of ...

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How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain? So why is the typical “cycle time,” the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour? Answer: Mandated screening activities that could actually be done in different ways and ...

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A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock. This “system” often doesn’t work, because of the way medical specialties are divided up. If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the ...

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