Small Changes, Big Dividends

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Hello and Happy New Year!  I know I took an unexpected blogging hiatus, and while I did plan on taking a small break through Christmas, the rest was, well, unfortunately not how I thought things would go down. I’ll come to talk about things soon enough, but for now I want to concentrate on getting some “real” content flowing. I refuse for the blog to continue to go stale because of things as mundane as personal problems.

Tuesday is an historic day as we swear in our 44th president, Barack Obama. Personally I’m jealous I don’t live in the DC area anymore (Fairfax County across the river, same difference) because I’d love to be part of a part of a part of something that day. Oh well. But it’s just a day in the end, and much work needs to be done in our nation, one of the most pressing issues being health care reform. I’m neither a practicing physician nor a policy analyst, so I’m not going to embarrass myself with attempts at unoriginality against such smarter people, but I can say what works from a patient’s perspective, especially one who can see both sides of the issue natively. “What do you mean? What do patients have to do with health care reform?”  They’re intimately involved in it! Left out of so many policy discussions, the patient-end of the equation is critical, but more on that later.

This last November I had a silly incident with my wrist and the side of a car that hurt at the time but I blew off, blaming as much my clumsiness as anything else. After weeks of not feeling better and rest/anti-inflammatories not making a difference, I finally got it looked at and wound up at this hand-specializing orthopedic surgeon, MRIs in hand (ha ha) showing a tear (that’s a separate post).  I was very impressed with him and his approach, appreciating his conservative management style. I normally don’t let on I’m a med student for a variety of reasons, but he asked what I studied (chart said “Occupation =  student”) and when I told him, he became even more effusive and engaging. Interestingly enough, we talked mostly about policy issues! (it’s on everyone’s mind right now!)

Regarding my condition, he said he wanted to do a steroid/lidocaine injection into the joint space to give short-term relief, re-evaluate in a month. As many of you know, I’m a classical pianist, and while I don’t play regularly these days, the very idea of a complication that could compromise that aspect of my life mortifies me, so I’m happy with baby steps. He’d be back in a bit and added, “Oh, and I have a letter for you,” as he handed me a piece of paper that for whatever reason I noticed immediately was both hand-signed and on good cotton-fiber paper stock. Still a bit taken aback, I asked, “What’s this about?”  He smiled and said, “I’m an old-fashioned guy, that’s all. I’ll be back in a bit,” and closed the door, instructing the other side for his assistant to begin the prep for the injection.

As I waited, I read this hand signed letter. Here are the relevant excerpts:

A Personal Letter From Your Doctor, MD

Dear Mr. Cantu:

Thank you for coming in today to consult with me regarding your medical care. I appreciate and respect your trust in me as your doctor and orthopedic surgeon. I strongly recommend you share in the responsibility of treating your condition. You can do this by following any medical advice given and keeping scheduled follow-up appointments. Timely follow-up is extremely important as delay in treatment could lead to deterioration or, even worse, permanent dysfunction.

On occasion, delays occur in the office. I ask for your patience as these delays are due to attending patients with complex issues. We will try to keep you informed when such delays occur. I assure you that should your medical problem require extra time, it will be fully provided.

Lastly, it is the policy of this office that all proven conservative (non-surgical) treatment options will be embarked on firstly. Surgical intervention is only offered if conservative treatment fails to alleviate your symptoms.

[closing paragraph, thank you, etc]

Is that awesome or what?  I also noticed in the letterhead the abbreviation FRCS for Fellow of the Royal College of Surgeons in the UK (he’s also an American FACS here, for what it’s worth). He had mentioned training in Canada (his ethnic origin is Caribbean of some kind, didn’t ask) but obviously there is some of that “English gentleman” thing going on here. I know good and well it’s a form letter coming off a laser printer at the last minute before entering the room, but it doesn’t matter. And if doesn’t matter for me, someone who sees what the wizard is doing behind the curtain, imagine how much more it can make a difference to an average patient, particularly older patients, who truly feel that they “connected” with their doctor in a unique and personal way–and on the first visit!

But the story doesn’t end there. After the injection I was waiting for 10 minutes or so to make sure it all got nice and happy in the joint space. Sir Orthopod came in and sat down, and started dictating in front of me. I thought this was a bit odd, though it’s happened on occasion before, but it was always when I was in a physician’s office already or in a hallway; in other words, it seemed like it was just occurring as a matter of course. This was different–he came into my exam room on his own volition, sat down, and started dictating into a digital recorder. He even paused once or twice to make sure he got something right, which he did, my thinking he was taking advantage of my being there out of convenience as I sat and listened patiently.

I thought during this he might just be more at ease because by this time he knew I was a medical student and felt comfortable dictating the technical behind-the-scenes in front of me, but in talking with him later, he said that he does that with all his patients. I was shocked! On the surface, it sounds like no big deal, but there’s a lot that can be said that can be taken the wrong way/misunderstood by someone who can’t parse the terminology/jargon, or feel that the physician “didn’t tell me that,” when in fact s/he did, they just used laymen’s terms in the conversation. But the surgeon said he does that intentionally to further avoid liability and increase transparency. It’s rare and more comes up with worker’s compensation and disability claim-type cases he said, but it’s very hard to claim “I had no idea,” when his standard practice–and that’s the key–is to dictate in front of the patient. The dictation is transcribed to the official record, and if the patient is present, that’s yet another opportunity to both 1) correct the record as it’s being dictated should the physician get something wrong, and 2) provide a legal support structure against false/misleading claims. Add a personal letter signed by hand, encouraging patient cooperation and apologizing in advance for minor inconveniences, etc. and you have a framework for the following:

  • a happy patient who feels listened to and cared for (less likely to sue, far more likely to refer word-of-mouth to friends/family)
  • a physician who knows how to invest, having just spent about $0.02 on a sheet of good paper stock and 1 second signing a letter for literally countless dollars of saved legal headaches, increased referrals, pleasant encounters, etc.
  • a physician who spent ZERO extra time, but by dictating in front of the patient provided extra legal protection, greater fidelity of the medical record, and further fosters a sense of transparency and trust with the patient
  • a patient whose medical expectations are manged from the start, thinking that because they were referred to a surgeon they need/will have surgery
  • a patient whose expectations are managed WRT office wait times not only by telling them it can happen but assuring them their care will not be compromised when its their turn. This also takes the heat off of the front staff, and happy staff makes all the difference too.
  • and perhaps most importantly, a patient who is invited to take an active role in partnership for their own care, hopefully achieving greater compliance for not only better outcomes but lower healthcare costs by avoiding complications, unnecessary procedures, etc.

The small steps taken by this doctor might seem trivial on the surface, but to me they’re genius because they accomplish so many good things in an honest way so effortlessly. The goal here is patient satisfaction and success with the added legal protection a bonus. This is just one relatively medium-sized solo practice in a small-medium south Texas city. Imagine if small changes like these were implemented everywhere, how much morale and rapport could improve, frivolous lawsuits could be avoided (or at least provide further disincentive), and how much the climate could change for the better all-around. I’m not idolizing this guy, I’m thinking beyond him to the bigger picture.

The other thing about his attitude, reflected in his letter, is the participation of the patient in their own care. We keep talking about health policy and reform from a top-down approach, changing insurance policy structures, provider reimbursement schedules, etc. rather than a bottom-up approach. While anyone really involved knows it’s a two-pronged approach, the media, and more importantly, too many patients feel they are mere bystanders in both the discussion and the solution, and I appreciate this physician opening the door to that reality for his patients. More on patient responsiblity in a separate post.

  • By Victoria Powell, January 18, 2009 @ 2:07 pm

    I am so glad you took the time to post this. As a Work Comp nurse I have had the pleasure of meeting other physicians who practice this way and it makes a huge difference in the patient’s mind. My personal PCP always dictates in the room with me and on several occasions we have commented/discussed things during that time to clear up any misunderstandings. Patient’s oftentimes think that something secretive must be in their records since they are often difficult to obtain. Wonderful post. Looking forward to more.

  • By Strong One, January 18, 2009 @ 3:20 pm

    Trivial.. Hell no. I wish this was the normal practice of all physicians!
    I worked for/with an ortho (ironic) and he did the very thing you’re discussing (aside from the letter – which was way kewl).
    It encapsulates what we as patients and providers wish for.
    Glad you were cared for in such a profound manner. Best of luck with that tear. I know TFCC tears are a B@TCH.

  • By Christine, January 18, 2009 @ 3:25 pm

    Stumbled across your blog and had to comment on this – I couldn’t agree with you more. I’m not in the medical field, let me state that first. I saw a neurologist a few years ago for recurrent headaches. He was Canadian, but had moved to the US for whatever reason (I’m in Ohio). The exam was completely different from the rush-rush 5 minute deal I’m used to, and after he made his diagnosis, he dictated not only his office note, but the consult letter he was sending to my PCP. We then chatted about the state of healthcare. Amazing. If only he were a PCP……………

  • By Karina, January 18, 2009 @ 4:13 pm

    Thank you so much for posting this. It is inspiring and a wonderful lesson.

    I still like to write physical social letters up to this day and on occasions I’ve been asked why I bother when there is email. I smile back but lightly saddened that the behavior may be akin to something peculiar and unusual anymore. But THIS warms my day. Thanks!

  • By rlbates, January 18, 2009 @ 5:11 pm

    I’m glad you found a hand surgeon you are comfortable with, Enrico. So happy for you (well not the injury). Take care.

  • By dr b, January 18, 2009 @ 10:22 pm

    This illustrates some good advice I received early in residency: ” A good physician makes 5 minutes feel like 20 to the patient”

    This is not trivial (especially in today’s high volume environment), but also not impossible

    Listen
    Eye contact
    Repeat things the patient has said back
    Sit down if possible (a subtle way to ‘slow down’ time for the patient)
    Modification of treatment plan, however trivial it may seem to YOU, based on patient feedback/compliants if medically reasonable
    Force some patient ownership of their own treatment (it gives you leeway later if things don’t work if they feel they “chose” the treatment, although in the end 99% choose what you strongly recommend anyway, and if it’s not important enough to warrant a strong recommendation, then hold on to the “dammit i’m the doctor” chips for later!)
    Get rid of the GOD complex

    In retrospect, I think this all is in the SPIRIT of the ‘manners’ article referenced earlier. Unfortunately, as is common in many corners of the medical establishment, the comments from the ‘blogosphere’ following the article dismissed or ridiculed the article partially based on the authors board certification (psychiatry). But the suggestion to at the least evaluate your practice techniques in light of the new “patient-centric’ paradigm that is gaining ground is a good suggestion for ALL, regardless of how applicable the details may be to any individual specialist.

    My 0.02 cents (well, more like a dime, that was damn long!)

  • By purplesque, January 19, 2009 @ 7:34 am

    Great post, E! I think your orthopod is wonderful, and there are lessons in there for all of us. In psych, things are quite often not as transparent, but I always call family members/other doctors in front of the patient. Most of them seem to appreciate that.

    *Goes to buy good paper stock*

  • By enrico, January 19, 2009 @ 8:19 am

    What a great discussion so far,thanks to all you for commenting! I did want to mention something that I thought of but neglected to mention in the article. I realize it’s far easier to take this more measured approach as a subspecialist (this doc does only hands/upper extremeties w/in the confines of already being specialized as an orthopod) with a far more consistent patient population than, say, a hectic family practice doc seeing just about everything that could possibly come in the door. While this fact is totally not lost in my mind, I think the general principles still apply. Perhaps a similar letter can be mailed after-the-fact for first-time patients, for example.

    There are lots of ways to make small changes to both empower patients, increase physician satisfaction in their practices and improve the overall healthcare climate in this country. We just need to be creative and sensible as much as we are willing to throw money around.

  • By Beach Bum, January 19, 2009 @ 8:30 am

    As a pianist, I hear you about the hand injury thing. I’m currently working through an injury to my left thumb (MCP joint), and while it’s not a huge injury, I’m still paranoid and panicked about it. Hope you’re better soon.

  • By dr r, January 19, 2009 @ 10:53 am

    At the VA, the 100% electronic records system forces you to learn to multitask typing your H and P while simutaneously engaging to patient in a a manner that they find fulfilling.

    So, the simple act of talking into a dictaphone is no big whoop (although I used to always write up my H and P outside of the room in other clinics, strictly due to time constraints (hate to say it, but with the county clinic workload (Ben Taub in houston), inturuptions during script writing, H and P’s etc added up in a way most clinics don’t)

  • By dr r, January 19, 2009 @ 10:55 am

    not belittling your doc, but removing excuses for other docs. :)

    -R

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