Kyle Bradford Jones, MD

I admit it - I watch medical television shows, and have recently been binge-watching the "House, M.D." series. My wife cannot understand because, as she says, "You live it all day long, and then you want to 

 it on TV?" Maybe it's because I like to appear smart by pointing out the ways in which the writers got a medical term or concept wrong. Maybe it's because I want to imagine my practice as dramatic as those on TV, saving lives in a thrilling and effective manner. Or maybe I just find it entertaining. Regardless of the reason, I have found that I actually learned some things from the curmudgeonly brilliant diagnostician Gregory House, MD, that have actually made me a better physician.

The history and physical (H&P) is paramount

Dr. House runs the lone department of diagnostics (in the country) because of being so gifted at diagnosing patients that no other physician could. He is also the epitome of a jerk. He has the tactless habit of not lowering himself to 

 his patients, but instead relies on his carefully chosen team to do the "dirty work." In many of the episodes, he ends up finding that diagnosis by hearing something about the patient's condition that his team failed to mention initially, creating a great epiphany. It will then frequently follow that he will go into the patient's room and point out an anticipated physical exam finding that his team missed, confirming his suspected diagnosis and saving the patient. The importance of the H&P continues to slip as more and newer technology gains wider use, but if you listen closely enough, the patient really will tell you what the problem is.

The first noticeable thing about Dr. House is that he has a considerable limp and walks with a cane due to a prior major surgery on his leg. He is also addicted to narcotic pain medication. This occasionally leads to questionable decisions made in his patient care.

This obviously brings up very relevant and significant issues in physician mental health, substance abuse, and even suicide. There has been more press about these issues in recent months and years, but there are likely thousands of physicians with mental illness and/or substance abuse that have yet to seek help. The show raises these substantial concerns in the personage of Dr. House, who is visibly miserable and whose life appears in shambles due to his chosen profession and substance abuse. Help is eventually sought, but only after years of heartache to himself and those close to him.

Think outside the box, but play the percentages

Dr. House does not play the percentages when it comes to diagnosis. Being the best at recognizing unusual diagnoses, he can often fail to see more likely (and thus boring) conditions at the expense of the patient. A large differential diagnosis is crucial to make sure that something is not missed, but understanding the odds of the most likely diagnosis and successful treatment should be focused on first. It's exciting to make diagnoses that your colleagues have forgotten about or never heard of, but the reason they are referred to as rare is because, well, they are. One of the best ways to counteract this is to not be confined by the diagnoses specific to your specialty. Think outside the box, but act within the odds of what the problem most likely is.

For all of Dr. House's faults and eccentricities, he will fight tooth and nail for his patients. He will buck all administrators, colleagues, and standard practices to ensure that his patient gets the utmost care to save or improve their lives. Patients obviously come to us at their sickest and most vulnerable, at a time when they most need an advocate against any barriers they may be facing. Patients may not have a way to recognize the extent of your medical knowledge, but they will never turn on someone who fights fiercely for them.

While "House, M.D." is a dramatic television show with multiple inaccuracies and stretches of reality, it can provide some directions and reminders for physicians on how to improve ourselves in a challenging profession. In the end however, you don't need to be brilliant or have your own television show to be a good physician.

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What I've Learned from Watching 'House, M.D.'

As an intern I participated in a rural rotation in central Utah. I worked at a clinic that was one of four in a valley that was approximately 70 miles long. I was amazed at the extent to which the family physicians were able to perform a wide variety of procedures and treat multiple conditions with fewer resources than they were accustomed.

Because they were competing with three other clinics, the physicians at this practice wanted to ensure that they saw as many patients as they needed to keep up their business and avoid losing patients to one of the other practices. One day a 4-year-old boy was brought in for symptoms of an upper respiratory infection (URI). After a bacterial infection was ruled out, my attending offered prednisone as a relieving agent while he healed from the URI. Prednisone, I thought? "It will help dry up his runny nose, give him some energy, and he'll be back to himself in no time," he explained to the mother. I was taken aback and asked him later why he would give prednisone, a powerful medication with plenty of significant side effects, to a child for a URI.

"It helps them feel better faster. They came in expecting something for his cold. If I don't give him anything to help, next time his mother will take him to one of the other clinics down the road and I lose them as patients."

After returning to my community hospital following this month-long rotation, I heard word that the hospital wanted to increase the number of obstetric patients that deliver there. Many providers had stopped referring their patients to deliver at this hospital due to some substantial safety and quality concerns, to the point where there was very little volume of deliveries and the hospital was losing money on the labor and delivery floor. If the administration addressed the safety issues, I thought, it would definitely bring back the business.

One week later, the construction of a new floor and overhaul of the delivery rooms began. I wasn't sure what was going on until I realized that this was the administration's way of competing for more patients; if the area is more attractive, of course more patients will come! The smell of the floor glue and other chemicals quickly became apparent and soon engulfed the entire labor and delivery area. But deliveries continued, babies remained in the nursery where the fumes were present, and everyone who worked there had to try to get accustomed to the odors. The administration was fearful of temporarily closing down the unit to avoid losing further patients.

I share these stories to illustrate how competition in medicine often works. Both of these occurrences were before the recent extreme push on patient satisfaction, but they were done in an effort to draw in more patients through satisfying what officials thought were critical needs. With our practices and hospitals being business entities, it is not surprising or even wrong to try to draw in more business; this is natural in our current system. The problem comes when patient safety and quality of care are overridden in order to bring in more business.

As the quality and cost of the care that we provide become more transparent, they will need to become the basis on which we attract new patients. Patients will look for value (quality plus patient satisfaction provided at a reduced cost) and will respond to those practices that demonstrate it. We are all aware of some of the pitfalls of this method of evaluation, but the best we can do is improve the metrics, not change the principle.

This, however, requires a major change in mindset by all healthcare entities. We cannot continue to compete on trivial and potentially hazardous grounds; we must start competing on what our patients actually need, which is quality care for as low a price as possible. Though the transition will be difficult, we cannot cover up the problem with a little prednisone to make us feel better.

A designer waiting room will surely impress new patients, but will not affect the quality of care you provide. Make sure you focus on meaningful metrics.

Competing for New Patients at Your Practice

For better or for worse, I have always been a big proponent of the Medicaid program. Starting with some research of pediatric patients receiving Medicaid as a medical student, as well as always having an inclination to care for those in most need, I have long backed this up with advocacy at both a grassroots and legislative level. The problem with advocacy for physicians, however, is that it takes a lot of time and emotional energy, and most of us simply do not have that to give, in addition to caring for patients.

Physicians who do not actively participate in advocacy tend to complain about what is or is not done on certain issues impacting themselves and their patients. Physicians who are actively engaged in advocacy efforts tend to complain that not enough physicians are involved and so should stop complaining unless they are willing to participate.

The trick is that both are right, and therein lies the catch-22 - you’re damned if you do and you’re damned if you don’t.

As we all know, the legislative process can be as fluid as molasses - it takes forever to get anything done. Even then, it requires a lot of know-how, understanding of the intricacies of the political process; and time to foster relationships, compete with other interests that may have opposite viewpoints and often higher-paid lobbyists, and change policy that may be a low priority or extremely unpopular in certain crowds.

This may be somewhat easier on a more local and state level, but still requires all of the above.

Many physicians see this as trying to move a mountain with a shovel, and indeed it sometimes takes just as long. Some of the legislative goals that organizations have may involve a multi-year plan, trying to gain small steps along the way, which can be very frustrating to those of us who are in clinic every day and see the needs and issues that we think should change.

So the question becomes how can we engage, or even, should we?

The hard truth is that nothing changes without our involvement, or may change for the worse for us based on the efforts of other special interests. So how do we fit this in to our busy and oftentimes draining schedule?

The important thing is to not be overwhelmed by the process and instead, focus on small steps. Tell your legislator your concerns. It is true that physicians are more listened to by lawmakers than nearly any other profession. Send an e-mail, chat on the phone or in person, and offer yourself as a resource on medical issues.

Oftentimes this may lead to invitations to testify in committee meetings, though this may certainly cause conflicts with clinic time. Only do as much as you’re comfortable with, but start the process.

As we all know, there are many important issues that need to be addressed. As I mentioned above in my interest in Medicaid, I have been working hard to forward Medicaid expansion in Utah, with both community organizations and legislators. It has been a long road, three years in coming, and the plan that would cover more than 100,000 citizens that most need it recently was voted down in favor of a lesser plan that would provide reduced coverage for nearly half as many people at the same cost.

It has been little more than a political game, which is hard to watch. And yet, it never would have gotten this far without so much physician support.  We likely would not even have the lesser option if we ignored the issue completely.

No matter what your issue of interest is, working with legislators, community organizations, or private organizations, even in a limited capacity that doesn’t overwhelm you, can make a large difference.

Many physicians compare efforts to initiate policy changes to trying to move a mountain with a shovel, and indeed it sometimes takes just as long.

Advocacy for Physicians is a Catch-22

A 42-year-old woman came in to see me recently complaining of some mild diffuse abdominal pain that coincided with constipation over the last couple of weeks. She had been completely symptom free before that point, and lacked any alarm signs that would suggest a serious medical condition.

“My sister has a friend who developed constipation and it was because of a large tumor in her colon. I am so worried about cancer that I haven’t been able to sleep for the last few days. I would like a colonoscopy to sort through this.”

In my medical opinion, there was no reason for a colonoscopy, but this was by far most likely simple constipation that could easily be resolved with laxatives and/or increased water and fiber intake. But it brings up a point that we experience nearly every day: How do we (should we?) handle patients who use anecdotal evidence to jump to unlikely conclusions?

It’s important to remember how we are trained to think versus how the typical person thinks. To this woman who heard a story of colon cancer, she thought this very likely could mean the same for her based on “similar” symptoms. From our perspective, the N of 1 for an unlikely outcome means almost nothing. But this is how people tend to think and approach problems - anecdotally, with personal stories.

As physicians, we have been taught to look at population-based studies to influence our decision making. We will look for sample size and power to ensure that enough people of the appropriate demographic and variable risk are included in order to ascertain a valid outcome. Oftentimes thousands of people included in a study are not enough to fit the need for a study.

We also tend to think in a probabilistic manner. Based on the history and exam that I performed on my patient with constipation, I may assign roughly a 90 percent chance of standard constipation without any complications, and maybe about a 1 percent chance or less of a malignant colonic mass.

The odds are strongly against anything serious, but at what point would you consider a colonoscopy? What if you determined a roughly 5 percent chance of cancer, is that enough for a colonoscopy? Ten percent? Would it need to be more? These are difficult questions and require patient input, as well as oftentimes input from other physicians.

Because of this, when we hear from a patient these anecdotal stories of one person, we are not too inclined to believe it and may then discount the patient and possibly our relationship with him. The trick comes in properly communicating our thoughts to the patient while keeping in mind his concerns spurred on by the anecdotal story. Specifically stating that this is what we think and why tends to go a long way toward understanding.

As we all know, sometimes this isn’t enough and the patient continues to request a test that is not indicated. This is obviously treacherous territory. Compromise is often needed with the hopes of not wasting resources and putting the patient in danger. Risks and benefits need a serious discussion to hopefully ensure the patient will be willing to follow evidenced-based recommendations.

Is there enough time in our brief visits to have such discussions? Not always, which tends to lead to dissatisfaction, and even malpractice suits. Hopefully newly recommended payment models based on value will assist in improving this problem, but that is yet to be determined.

One of the most crucial aspects of patient relationships is understanding the different ways in which we have been taught to think as compared to how patients tend to think about medical problems. This awareness will lead to much improved care and relationships with patients.

One of the most crucial aspects of patient relationships is understanding how our thinking as physicians compares to how patients tend to think about medical problems.

When Physicians' and Patients' Perspectives Differ

As a resident, I was assisting in the care of a woman in her 60s who was due for a repeat EGD due to her ongoing Barrett’s esophagus.

“Can we help you schedule it here with Dr X?” I asked.
“No thanks, I always get this stuff done down at the Costco hospital. I just like the atmosphere better there.”
“Costco hospital?” I was slightly confused.
“Yeah, the hospital a few miles away with the Costco in the parking lot,” she replied, as if what she was referring to should be clear as day.

There was a very good, very large hospital fairly nearby that did indeed have a Costco in the parking lot. The hospital offered nearly any diagnostic need or treatment you could imagine, so the comparison between the hospital and Costco seemed quite apt.

This stirred my mind. Could this comparison be pertinent to our nation’s healthcare?

Over the past 100 years, healthcare has grown from a very simple, almost cottage industry to a behemoth that is taking over our economy and can reasonably be compared to a superstore where anything you can think of is available, and at very large quantities.

I would argue that a significant contributor to this (though there are certainly many) is the expectation that physicians and healthcare institutions will address many personal and societal issues that influence health and illness.

Please don’t get me wrong. Addressing the social determinants of health is crucial to health, both to acute infectious diseases, as well as chronic illnesses. But often the burden of these solutions falls to physicians (and primarily primary-care physicians) within the context of a 15-minute appointment.

Due to lack of time, lack of training, lack of reimbursement, and the lack of ability to address many of the needed issues, often the patient and physicians are left feeling frustrated and a bit hopeless.

This alone oftentimes leads to a vicious downward spiral in the patient’s medical care, where more diagnostic tests are ordered and more medications are prescribed as Band-Aids to the problem, which then causes worse health outcomes, and further frustration.

This also promotes the current frustration among many physicians of quality metrics based on outcomes, many of which are outside of the physician’s control.

What can we do if our patient with diabetes can only afford food that is high in carbohydrates, has some difficulties with understanding how to address her illness despite our best efforts at education, and has transportation issues with coming to the clinic?

It is an unfortunate reality that our medical organizations are not able to solve these issues, despite the best of intentions.

Some “Costco” healthcare institutions have been built with the idea in mind of filling every diagnostic and treatment need a patient may have.

This has likely contributed to this expectation among society and patients that everything affecting health can be addressed and solved.

Many physicians have also contributed to this mindset with how we approach our patient’s medical needs.

So we need to decide: Do we want healthcare to be a Costco for our country, with the illusion of providing anything and everything you could want, as is oftentimes portrayed? Could we incorporate more multi-disciplinary teamwork, including social workers, Health and Human Services employees, and/or public health officials to attempt to solve some of these problems? Or should we scale back and simply address the issues that we have been taught in our training?

The questions do not have a clear answer, though as our structure has been moving towards increased teamwork to help with some of these concerns, it is important to consider what we want our healthcare system to be.

There is an unfortunate expectation among society and patients that everything affecting health can be addressed and solved. 

Costco-Like Health Systems: Has Medicine Outgrown its Limits?

Patient-centered care seems to be a popular buzzphrase among policymakers and administrators in recent years. Indeed, many physicians see our healthcare system as payer-centric, many patients see it as physician-centric, and no one seems to see it as patient-centric.

While putting the patient at the center of what we do as physicians is critical to improving the triple aim of better care, better health, and lower costs, it is important to keep in mind what this exactly means.

Patient-centered care is not the same as patient-directed care

We have all experienced patients who demand certain tests or treatments and see the physician’s role as merely rubber-stamping whatever is desired. This is a common trait among millennials, but also older generations who now have access to all sorts of information, both correct and incorrect, through the Internet.

Though these patient requests are sometimes accurate and warranted, they often go against medical evidence or our clinical judgment as physicians.

The example often given is of a patient with a viral upper-respiratory infection who demands antibiotics. Many physicians fear negative patient satisfaction scores or losing a patient in a competitive market, and so will prescribe the antibiotics as the patient requests.

This has obviously negative ramifications for antibiotic resistance and poor care, but these are the incentives that have been set for us by many payers and administrators. It is only human nature to follow the incentives.

Patient-centered care does not have to be something that compromises our practice.

Patient-centered care does not mean physicians must give full decision-making autonomy to the patient, just as routine care does not demand that the physician provide full-decision making.

It has been shown that many patients who demand certain care, such as antibiotics when not warranted, do respond to proper communication and explanations of why it is not merited. An acknowledgement of their desires is critical, but an informed discussion of why the request is not appropriate should occur.

This is actually the definition of patient-centered care - allowing the patient to make an informed decision together with the physician. A respectful, trusting relationship obviously improves this discussion and the patient's willingness to listen to medical evidence and expertise, but even more acute settings where a long-standing relationship has not been established can be successful in these aspects.

Challenges physicians face due to patient-centered care

The problem inherent in this advice is that physicians' schedules and time with patients are being squeezed. How can we expect patient-centered care, patient satisfaction, quality of care, or even physician satisfaction, when the system has been moving toward less face time with patients and more administrative duties for so long?

It’s quicker to write a prescription than to take time to explain to a patient why the prescription isn’t necessary.

Many of us feel that payers and administrators are setting us up for failure by providing incentives to increase RVU production while also providing incentives to improve quality and provide patient-centered care. These two goals often seem contradictory.

The trusting relationship with patients is being undercut by competing demands, lessening the likelihood of satisfying the patient. This then contributes to a payer-centric and perceived physician-centric way of caring for patients.

Hence, dissatisfaction among physicians, many of whom desire to leave the profession.

True patient-centered care can actually improve the quality of care and decrease the cost of unnecessary and potentially harmful testing and treatments. Hopefully, proposed payments that incentivize team-based care and move away from fee-for-service will provide the ability to spend more time educating patients, both by the physician and by ancillary team members.

While physicians are not merely around to sign off on anything a patient wants, the discussion, trust, and education of patients moves the perception of care from patient-dictated to patient-centered.

That may mean losing some patients who absolutely demand having what they want, but it will also strengthen the bonds with many patients in your practice. After all, that is the reason so many of us entered medicine in the first place.
 

We have all experienced patients who demand certain tests or treatments and see the physician’s role as rubber-stamping whatever is desired. Here's how to deal. 