Most of medical school and residency is like this. I know the accreditors are pushing for more continuity of care in the primary care specialties, but that’s an uphill battle. In general, the only patients whose ultimate disposition I know are the ones who died in front of me, and I got occasional continuity on the outpatient side. The hospital side there are patients you get to know pretty well but that’s kind of a problem because a lot of them shouldn’t be back in the hospital every month but they are.
What a profoundly insightful reflection! Embracing candor and despite the risk of seeming unsophisticated, I am compelled to share my recent experiences with a healthcare provider. This revelation surfaces at an especially appropriate time. It's been a constant source of bewilderment to me when a physician declares my test results as 'normal,' even when certain metrics, highlighted in red, deviate noticeably from the standard range. My initial endeavor was focused on medicinal interventions, yet the direction I was steered towards involved changes in lifestyle and diet. The reasoning for classifying these divergent values as acceptable remained unexplained. I am steadfast in my belief that the caliber of healthcare could be greatly elevated if patient preference questionnaires were commonplace, evaluating whether a patient has a tendency towards a minimalist or maximalist approach to medication. After all, the foundation of any successful healthcare practice is built on effective and transparent communication. Please continue sharing such illuminating reflections, and do not shy away from including your wishes about what patients should or should not do, or what they should communicate!
Thanks for the thoughtful note. The challenge of the communicating the “normal abnormal” labs in a way appropriate to each patient is a challenge in the days of the EMR. I am still struggling with it.
Wonderful post. In 2008, after 25 years, I retired from my ID/HIV Office Practice in 2008 to devote the last 10 years of my career to full-time inpatient Critical Care and ID. I handed off most of my patients to the younger ID doc hired to take my place. My patients were sad.
In the proceeding 25 years I rarely was "fired" and when few of the patients let me know what they thought of me and my style.
During those years I kept a manila-folder labeled "Me File". It it I tossed every good or bad in-writing comment - greeting cards, Member Services complaints, lawsuit notices, patient telephone messages slips. Some of it was inpatient as well. When EPIC came around and the messages came across electronically I printed and saved them.
When I finally fully left clinical practice I brought all that material home - by then it was overflowing 10 inches thick and few years after that I sifted through it. Going through the all that material was a very profound experience. I'd see a name and my heart would begin to pound. I remembered most of those patients, especially the withering 4 page letter that criticized everything about me except my footwear. After 35 years that was one of about 10 negative encounters.
Although the positive "thank yous" were satisfying, it was the far-outnumbered which bothered me the most. In 35 years I never got used to the hard fact that not everyone is going to like me.
I think I thought of Medicine as somewhat of a Holy calling. I was honored and humbled that someone would put their faith and trust of their, or their family member's, corporal beings in me.
It was exhilarating, and frightening, and what I miss most about practicing medicine.
Thank you Dr. Cifu. This paper rings 2 bells for me.
1 - I left my doctor I had seen for 20 years because of several different reasons, but the biggest reason is no one took the time to get to know my personality and work with it. One day one of his staff said something so insulting and insensitive I never went back. She had known me for 20 years also. I just assumed, despite my longevity with him, my absence wouldn't be given a second thought. Maybe it is and maybe it isn't.
2- In hospice the PCP usually gives the hospice medical director full care of the patient because hospice is such a specialty. Because of that I didn't think the PCP, despite giving up total care of the patient, would care if I called him/her about the death of his/her patient. I assumed that each PCP has so many patients that come and go through his/her revolving door one patient wouldn't be missed. I hear you, doctor, say that there is a very good chance the patient's PCP does think about him/her despite leaving their care.
Because of this sharing I will be more sensitive and keep that PCP in the loop of his/her patient's death. Maybe that one patient was the one that caused that doctor's sleepless nights.
Having been a consumer of care and a care provider this is a raw and real perspective. I recently had a pretty major surgery and - lord willing - I won’t have to see my surgeon (also a former colleague!) for this for awhile, if ever! But because we worked together I have no problem texting him and letting him know how I’m doing. Flashback to youth and the tethered spinal cord surgeon, the urostomy surgeon, and the many ortho surgeons who made it so I could walk. They were gods to me and I was thankful but reverent! They were all knowing in my mind. So THIS reminds me to be aware and to make sure to communicate the good, too. Many of my ghost patients are sadly ghosts now due to OD and attempts to shortcut addiction. I’m old school - I go for the long haul treatment of lifestyle change. But I see my ghosts who are still alive in the community, paying their addictive behavior debts forward and helping others. Others I think of and just hope they are ok. Thanks you, Dr. Cifu, for this reminder that we are not humans having a spiritual experience, but spirits having a human experience.
We're with Kaiser (not my choice, my husband's). So I always assume that the doctors in "the system" see me as a number rather than a patient. There are a couple of doctors that we know well because of my kids, and if/when we leave Kaiser, I will be sure to say goodbye to them, though I suspect that they will assume that my kids "left their care" after aging out.
Fascinating. At times, I think about this from the patient side. There are doctors who *REALLY* seem to care. But after one or two post-op visits, you no have a need to see them. In some cases, I sent a gift basket thanking them. Interesting to read that the physician's side.
I, too, have a ghost panel. As a primary internist, there are aspects of it which haunt me. I automatically assume fault when I learn someone died. "I must have skipped over a lab or a path report," I think to myself. And that's for the "ghosts" I learn about. What about the ones I have no earthly idea have left me?! I have to consciously seek reason in those moments, realizing I am, indeed, fallible AND selfish. I am fallible in that I am man: perfectly capable of making mistakes. I am selfish in that I automatically think it's always about me. And it's not...very rarely is it something I have done (other than refuse to hand out narcotics). "That's life," as Sinatra croons. Life as a primary internist is being that steadfast rock in a fast moving stream. It's immovable and can always be counted on in the community. Some things will glide past it, collide with and off of it, or cling to it. But, that's life.
Yes. With almost every death I was left with the feeling that somehow it was my fault and that only if I'd done something else, or better, things would have different. I had a difficult time with my own mistakes - I often referred myself to the Quality Department when I made a mistake only I knew about.
I felt the same way when I asked hospice to make sure my dad wasn’t in pain. I was known as the “minimize opioids to the maximum” chronic pain clinician so when I asked them to be liberal for dad, people noticed. When he passed 12 hours after getting into hospice I thought, “My God it’s my fault he OD’d”. Which of course there was no OD. Took some time to throw my ego aside and now I am grateful he went in peace, and it had nothing to do with anything I did or did not suggest.
Most of medical school and residency is like this. I know the accreditors are pushing for more continuity of care in the primary care specialties, but that’s an uphill battle. In general, the only patients whose ultimate disposition I know are the ones who died in front of me, and I got occasional continuity on the outpatient side. The hospital side there are patients you get to know pretty well but that’s kind of a problem because a lot of them shouldn’t be back in the hospital every month but they are.
What a profoundly insightful reflection! Embracing candor and despite the risk of seeming unsophisticated, I am compelled to share my recent experiences with a healthcare provider. This revelation surfaces at an especially appropriate time. It's been a constant source of bewilderment to me when a physician declares my test results as 'normal,' even when certain metrics, highlighted in red, deviate noticeably from the standard range. My initial endeavor was focused on medicinal interventions, yet the direction I was steered towards involved changes in lifestyle and diet. The reasoning for classifying these divergent values as acceptable remained unexplained. I am steadfast in my belief that the caliber of healthcare could be greatly elevated if patient preference questionnaires were commonplace, evaluating whether a patient has a tendency towards a minimalist or maximalist approach to medication. After all, the foundation of any successful healthcare practice is built on effective and transparent communication. Please continue sharing such illuminating reflections, and do not shy away from including your wishes about what patients should or should not do, or what they should communicate!
Thanks for the thoughtful note. The challenge of the communicating the “normal abnormal” labs in a way appropriate to each patient is a challenge in the days of the EMR. I am still struggling with it.
Your terminology—'normal abnormal'—certainly offers an interesting lens to view the situation through. Thanks!
Wonderful post. In 2008, after 25 years, I retired from my ID/HIV Office Practice in 2008 to devote the last 10 years of my career to full-time inpatient Critical Care and ID. I handed off most of my patients to the younger ID doc hired to take my place. My patients were sad.
In the proceeding 25 years I rarely was "fired" and when few of the patients let me know what they thought of me and my style.
During those years I kept a manila-folder labeled "Me File". It it I tossed every good or bad in-writing comment - greeting cards, Member Services complaints, lawsuit notices, patient telephone messages slips. Some of it was inpatient as well. When EPIC came around and the messages came across electronically I printed and saved them.
When I finally fully left clinical practice I brought all that material home - by then it was overflowing 10 inches thick and few years after that I sifted through it. Going through the all that material was a very profound experience. I'd see a name and my heart would begin to pound. I remembered most of those patients, especially the withering 4 page letter that criticized everything about me except my footwear. After 35 years that was one of about 10 negative encounters.
Although the positive "thank yous" were satisfying, it was the far-outnumbered which bothered me the most. In 35 years I never got used to the hard fact that not everyone is going to like me.
I think I thought of Medicine as somewhat of a Holy calling. I was honored and humbled that someone would put their faith and trust of their, or their family member's, corporal beings in me.
It was exhilarating, and frightening, and what I miss most about practicing medicine.
I’ve got a piece coming out next month on my “sunshine folder.” So true that the criticisms sting more than the compliments soothe!
Thank you Dr. Cifu. This paper rings 2 bells for me.
1 - I left my doctor I had seen for 20 years because of several different reasons, but the biggest reason is no one took the time to get to know my personality and work with it. One day one of his staff said something so insulting and insensitive I never went back. She had known me for 20 years also. I just assumed, despite my longevity with him, my absence wouldn't be given a second thought. Maybe it is and maybe it isn't.
2- In hospice the PCP usually gives the hospice medical director full care of the patient because hospice is such a specialty. Because of that I didn't think the PCP, despite giving up total care of the patient, would care if I called him/her about the death of his/her patient. I assumed that each PCP has so many patients that come and go through his/her revolving door one patient wouldn't be missed. I hear you, doctor, say that there is a very good chance the patient's PCP does think about him/her despite leaving their care.
Because of this sharing I will be more sensitive and keep that PCP in the loop of his/her patient's death. Maybe that one patient was the one that caused that doctor's sleepless nights.
Thank you.
Thanks for the note. I’ve always tried to keep close tabs on my patients transferred to hospice with another doc but it can be hard.
Having been a consumer of care and a care provider this is a raw and real perspective. I recently had a pretty major surgery and - lord willing - I won’t have to see my surgeon (also a former colleague!) for this for awhile, if ever! But because we worked together I have no problem texting him and letting him know how I’m doing. Flashback to youth and the tethered spinal cord surgeon, the urostomy surgeon, and the many ortho surgeons who made it so I could walk. They were gods to me and I was thankful but reverent! They were all knowing in my mind. So THIS reminds me to be aware and to make sure to communicate the good, too. Many of my ghost patients are sadly ghosts now due to OD and attempts to shortcut addiction. I’m old school - I go for the long haul treatment of lifestyle change. But I see my ghosts who are still alive in the community, paying their addictive behavior debts forward and helping others. Others I think of and just hope they are ok. Thanks you, Dr. Cifu, for this reminder that we are not humans having a spiritual experience, but spirits having a human experience.
Thanks so much for the thoughtful comment.
Thank you for sharing your perspective on this.
We're with Kaiser (not my choice, my husband's). So I always assume that the doctors in "the system" see me as a number rather than a patient. There are a couple of doctors that we know well because of my kids, and if/when we leave Kaiser, I will be sure to say goodbye to them, though I suspect that they will assume that my kids "left their care" after aging out.
Fascinating. At times, I think about this from the patient side. There are doctors who *REALLY* seem to care. But after one or two post-op visits, you no have a need to see them. In some cases, I sent a gift basket thanking them. Interesting to read that the physician's side.
Thanks. The comments have been interesting to read for me as they mostly describe “the patient side.”
I, too, have a ghost panel. As a primary internist, there are aspects of it which haunt me. I automatically assume fault when I learn someone died. "I must have skipped over a lab or a path report," I think to myself. And that's for the "ghosts" I learn about. What about the ones I have no earthly idea have left me?! I have to consciously seek reason in those moments, realizing I am, indeed, fallible AND selfish. I am fallible in that I am man: perfectly capable of making mistakes. I am selfish in that I automatically think it's always about me. And it's not...very rarely is it something I have done (other than refuse to hand out narcotics). "That's life," as Sinatra croons. Life as a primary internist is being that steadfast rock in a fast moving stream. It's immovable and can always be counted on in the community. Some things will glide past it, collide with and off of it, or cling to it. But, that's life.
We certainly share the way we react. Thanks for the note.
Yes. With almost every death I was left with the feeling that somehow it was my fault and that only if I'd done something else, or better, things would have different. I had a difficult time with my own mistakes - I often referred myself to the Quality Department when I made a mistake only I knew about.
I felt the same way when I asked hospice to make sure my dad wasn’t in pain. I was known as the “minimize opioids to the maximum” chronic pain clinician so when I asked them to be liberal for dad, people noticed. When he passed 12 hours after getting into hospice I thought, “My God it’s my fault he OD’d”. Which of course there was no OD. Took some time to throw my ego aside and now I am grateful he went in peace, and it had nothing to do with anything I did or did not suggest.
There is no way to say it better than you just did.