I remember Adam writing about his clinical coach in one of his substacks. Can anyone share that piece with me at akshaybaheti@gmail.com or over here? I have searched everywhere but cannot seem to find it :(
I don't think I have written about this before. I may be wrong; the downside of writing every week is not being able to remember everything you have put out there. Here is a link to the program I participated in.
I love this piece. “We need to remember that for some, time is more therapeutic than the newest biologic.”Totally true. And I definitely need "Do Nothing Stupid" t-shirts!
First thank you for the work you do inside the exam room and out!
One of the reasons I became a physician was to set myself on the path of eternal knowledge. We are always learning, what to do, what NOT to do, a colleague has a clinical pearl that alters our clinical prowess, we learn from our nurses, we learn from our residents, the list goes on. And it’s true we never do get around to looking at what we are doing well because of…too many excuses—no matter how well-justified. I think it would could really open up the algorithms we have embedded in our doctor minds. I mean this is really what drew most of us to medicine, right? Like this is the real meat and potatoes. Make connections in the biological puzzle and bring our patients closer to health and healing.
Adam, I find your comments to be very insightful, and refreshing in this time of corporate medicine. I can only wish that all practicing physicians shared your insight & wisdom. Keep up the good work! Robert R. (retired medical oncologist)
I worked for 25 yrs as a family nurse practitioner in an HMO. Now am retired. Am an active 91 . I read your notes and wish I had them when practicing. I am amazed by the current office visits of minimal/absent physical exam. But I remember the yield of problems was usually absent with all those inspections. It only put me way behind and made patients wait as 15 minute appts were not long enough. . Will the pendulum swing? Who knows?. Anne F.
Like others have said, the last line is so important. The way I tend to think about very old patients: they have achieved that advanced age *in spite* of the healthcare system rather than because of it.
But you know the flu shot has no positive benefit, so why do you still give it? Is it because people expect it? Why not educate them in the results of retrospective studies?
Re: the parting line. As a medical student in the late 80's, I did an elective rotation in a small town in west Alabama. I an 89 year-old gentleman brought in his mother for a check up. You read that correctly. She was a delightful and reasonably robust 108 year-old. If I recall correctly, she was on one or two meds for hypertension. Her BP reading may have been a tad high, but the LAST thing I'd ever do would be change anything.
These stories about maximally telescoped patients who don't have a problem make me a little nervous. I had to switch doctors to avoid being perceived that way. Plot twist: it ended up i was in fact seriously ill. It's all good now. If I see a primary care doc these days I have everything on a 3x5 card and I'm the most hyperfocused person they will see that day. Sometimes I will channel Adam and ask how a test will affect management.
At this point in my career I consider your patient time allotments
(20 minutes for return patients, 40 minutes for new patients, and 40 minutes for patients over 80 years of age. On any given day, some patients need a 60-minute appointment. They have multiple or complicated concerns. They need a detailed exam or a procedure. They require time to hear and process a diagnosis, a treatment plan, or a prognosis. ) a minimum.
I was offered a locum tenens position which scheduled 22-25 patients per day. These would all be new patients to me. On Tuesdays, the doctor saw 22-25 all new patients at 15 minutes per patient. I told them this was incompatible with quality care.
Yup. One of the major problems with current "big box" medicine: asking physicians to do 45 minutes worth of work in a 15 minute time slot. "meditation" and "wellness programs" can't fix that mismatch.
I sure wish my healthcare system recognized this as a minimum. Delivering quality primary care to 22 patients (new and established) per day in 20 minute slots is extremely challenging
Comment about all of your podcasts: the volume is set way too low, even at maximum I often can barely hear you (you have soft voce). Set ceiling of volume much higher and we can always turn it down. Thank you.
++We don't reflect enough when things go well. A corrollary is that we often don't even understand what we do that we think is just common sense or common courtesy or just human nature that turns out to be uncommon and makes a huge difference in outcomes.
++The patient-doctor relationship includes more than just the people in the room. Also, don't forget the doctor's support crew. The worst mistake I've ever made was related to my not wanting to trouble a support staff who was already having a bad day due to home circumstances. I am a better doctor when there is no friction between me and my support crew.
++Do not cheat patients who are there only for your time. These are tough ones for me and I think this is related to point #1 above. Surely, anyone could listen to this patient. Is this really the best use of my 40 minutes? And, yet, I can see that if I stretch the visits out to every 3 months instead of every 2, that they end up in the emergency department. But other patients complain that they can't get in to see me and that I'm scheduled out so far. I have not figured out how to resolve this one.
++Don't feel proud because you care for a very old patient. Well said. Avoid doing stupid things. That is good advice.
Hi, I'm a PhD mathematician and former NCI PI. I have strong feelings about medicine making the wrong definitions. I'd like to talk.
andreww@Maine.edu
I remember Adam writing about his clinical coach in one of his substacks. Can anyone share that piece with me at akshaybaheti@gmail.com or over here? I have searched everywhere but cannot seem to find it :(
I don't think I have written about this before. I may be wrong; the downside of writing every week is not being able to remember everything you have put out there. Here is a link to the program I participated in.
https://bucksbauminstitute.uchicago.edu/hart-of-medicine/
Thank you so much! I don't know whether I was hallucinating; more likely I read someone else's article. But I do hope you write on this sometime.
I found it Adam. It's by Atul Gawande. I remembered it as being an extremely insightful piece and, naturally, confused it in my mind to be yours!
https://www.newyorker.com/magazine/2011/10/03/personal-best
I love this piece. “We need to remember that for some, time is more therapeutic than the newest biologic.”Totally true. And I definitely need "Do Nothing Stupid" t-shirts!
I am curious, how does one procure a clinical coach?
This is our program. Might be a place to start.
https://bucksbauminstitute.uchicago.edu/hart-of-medicine/
First thank you for the work you do inside the exam room and out!
One of the reasons I became a physician was to set myself on the path of eternal knowledge. We are always learning, what to do, what NOT to do, a colleague has a clinical pearl that alters our clinical prowess, we learn from our nurses, we learn from our residents, the list goes on. And it’s true we never do get around to looking at what we are doing well because of…too many excuses—no matter how well-justified. I think it would could really open up the algorithms we have embedded in our doctor minds. I mean this is really what drew most of us to medicine, right? Like this is the real meat and potatoes. Make connections in the biological puzzle and bring our patients closer to health and healing.
Adam, I find your comments to be very insightful, and refreshing in this time of corporate medicine. I can only wish that all practicing physicians shared your insight & wisdom. Keep up the good work! Robert R. (retired medical oncologist)
Thank you Robert.
I worked for 25 yrs as a family nurse practitioner in an HMO. Now am retired. Am an active 91 . I read your notes and wish I had them when practicing. I am amazed by the current office visits of minimal/absent physical exam. But I remember the yield of problems was usually absent with all those inspections. It only put me way behind and made patients wait as 15 minute appts were not long enough. . Will the pendulum swing? Who knows?. Anne F.
Wonderful article, Adam.
Like others have said, the last line is so important. The way I tend to think about very old patients: they have achieved that advanced age *in spite* of the healthcare system rather than because of it.
Thanks Bobby!
"An adult child who is skeptical of medical recommendations might be at home, influencing a person’s adherence to medications." Guilty as charged!
Well said. Good advice.
But you know the flu shot has no positive benefit, so why do you still give it? Is it because people expect it? Why not educate them in the results of retrospective studies?
Re: the parting line. As a medical student in the late 80's, I did an elective rotation in a small town in west Alabama. I an 89 year-old gentleman brought in his mother for a check up. You read that correctly. She was a delightful and reasonably robust 108 year-old. If I recall correctly, she was on one or two meds for hypertension. Her BP reading may have been a tad high, but the LAST thing I'd ever do would be change anything.
These stories about maximally telescoped patients who don't have a problem make me a little nervous. I had to switch doctors to avoid being perceived that way. Plot twist: it ended up i was in fact seriously ill. It's all good now. If I see a primary care doc these days I have everything on a 3x5 card and I'm the most hyperfocused person they will see that day. Sometimes I will channel Adam and ask how a test will affect management.
Glad you're doing OK. Keep the comments coming, I really appreciate your takes.
At this point in my career I consider your patient time allotments
(20 minutes for return patients, 40 minutes for new patients, and 40 minutes for patients over 80 years of age. On any given day, some patients need a 60-minute appointment. They have multiple or complicated concerns. They need a detailed exam or a procedure. They require time to hear and process a diagnosis, a treatment plan, or a prognosis. ) a minimum.
I was offered a locum tenens position which scheduled 22-25 patients per day. These would all be new patients to me. On Tuesdays, the doctor saw 22-25 all new patients at 15 minutes per patient. I told them this was incompatible with quality care.
Yup. One of the major problems with current "big box" medicine: asking physicians to do 45 minutes worth of work in a 15 minute time slot. "meditation" and "wellness programs" can't fix that mismatch.
I sure wish my healthcare system recognized this as a minimum. Delivering quality primary care to 22 patients (new and established) per day in 20 minute slots is extremely challenging
" incompatible with quality care." Totally agree.
Thoughtful and reflective insights as always. Thank you Adam.
Thanks.
Comment about all of your podcasts: the volume is set way too low, even at maximum I often can barely hear you (you have soft voce). Set ceiling of volume much higher and we can always turn it down. Thank you.
Thanks. Does this apply to fortnight as well?
Yes. Thank you.
Fortnight is one of my favorites. I miss Vinay's oncology dissections.
++We don't reflect enough when things go well. A corrollary is that we often don't even understand what we do that we think is just common sense or common courtesy or just human nature that turns out to be uncommon and makes a huge difference in outcomes.
++The patient-doctor relationship includes more than just the people in the room. Also, don't forget the doctor's support crew. The worst mistake I've ever made was related to my not wanting to trouble a support staff who was already having a bad day due to home circumstances. I am a better doctor when there is no friction between me and my support crew.
++Do not cheat patients who are there only for your time. These are tough ones for me and I think this is related to point #1 above. Surely, anyone could listen to this patient. Is this really the best use of my 40 minutes? And, yet, I can see that if I stretch the visits out to every 3 months instead of every 2, that they end up in the emergency department. But other patients complain that they can't get in to see me and that I'm scheduled out so far. I have not figured out how to resolve this one.
++Don't feel proud because you care for a very old patient. Well said. Avoid doing stupid things. That is good advice.
Thanks Mary!