How did I finally reach my epiphany?

Well, one particular doctor (who shall remain nameless) has become famous in my field, as well as moderating famous around the country in the lay press, by promulgating a very specific theory for the last 20 years.  Although the theory does have some validity, this doc promotes it as the end-all-be-all of the issue at hand.  So much so that the doc now has published a book directed at patients who need help for their problem.  When I happened upon the book’s website, I noticed a picture of the doc standing together with another physician with a very famous TV show. (I’ll let this doc remain nameless as well, but if you are a wizard you’ll figure it out…)

It was then that the light went off about the key to getting famous…

Promote your agenda by being dogmatic

Here’s how you do that:

1. Speak in absolutes. Talk in black and white. Never bring up the shades of gray because that might confuse your target audience.  Words to avoid include: may, might, could, and possibly.  Instead choose words like: will, won’t, always, and definitely.
2. Incite fear in people.  Tell everyone that if they don’t follow your advice something bad will happen to you.  Like inflammation or dysfunction…those are hard to disprove.  Or maybe malaise, fatigue, depression, or other problems that have a hard time getting better.  Then your audience will believe you, because that’s probably why they’re listening to you anyway.
3. Never rely on science (“evidence-based medicine”), because only your opinion (“media-based medicine” #mbmed) counts. Studies with valid, patient-oriented outcomes are much harder to do and probably won’t prove your point.  So why waste the time and money, when being charming and loud is much easier to make sure people know you’re right?
4. Never admit that you don’t know. That will just show you are a failure and you will appear less god-like to the people you are trying to reach.

I’m glad that I figured that out. Now I don’t have to spend my time trying to understand and study complicated medical issues when I can just make everything fit my agenda. Whew, that’s a relief!

Oh, and this is a pretty good way to get elected to political office too.

A few days ago I was sitting in the endoscopy unit working on some notes, when one of my fellows walked into the physician’s room to speak to one of her patients over the phone.  The patient evidently had a lot of complex questions about her condition that she didn’t quite comprehend.  The fellow took her time to respond calmly and in straightforward language.  She didn’t rush and never became flustered or frustrated.  After about 15 minutes or so, their discussion ended and the fellow left the room.

Why am I telling you this story?  To illustrate an important point. 

I was all the way on the opposite side of the room, and the fellow probably didn’t consciously notice me.  While I was sitting there, I was not intending to judge her on her patient interaction.  While she was talking to her patient, she didn’t necessarily think (or care) that she might be getting “graded” on her conversation.  Nonetheless as I was working I was quietly taking in my surroundings and her conversation happened to catch my ear.  Without even realizing it, I was making an informal mini-assessment of her knowledge, skills, attitudes, and behaviors.

Why is this example critical? 

The interaction registered in my perception of her overall ability to be a gastroenterologist.  And maybe, one of my future colleagues.  I am pretty sure that she wasn’t thinking that the phone call would make or break her ability to be get hired.  Most people wouldn’t.  But add up lots of mini-assessments, outside of the context of a formal job interview, and an opinion about you has been formed.  For all intents and purposes, everything you do that someone else could perceive (see, hear, or read), could be used as a mini-assessment, and you might not even have realized it.  And that time you flippantly yelled at a nurse and then laughed about it later with your colleagues might come back to haunt you.

How has Social Media changed this paradigm?

Social media such as Facebook and Twitter provide a means for rapid communication with virtually anyone, anywhere, at any time. Such platforms have changed the model for the expectation of privacy. The younger generation will grow up with Social Media so entrenched in their lives that they may not recognize all the ramifications of a single reckless post. Information can now become disseminated faster and more broadly, sometimes even ruining people’s lives with just a single action, post, or tweet.

The topic of professionalism has been receiving more and more importance within medicine and medical training.  For those who have a hard time understanding its importance, I would tell you this:

Professionalism is the 24-hour-a-day job interview

And now that social media has entered the mainstream, we (as parents, teachers, doctors, etc.) need to educate everyone about its potential.  Medical students, college students…even high school students.  Certainly, actions in childhood have little effect on one’s professional life as an adult.  However a professional and courteous attitude toward others does not begin overnight.

If you care about young people, whether your own children, students you are mentoring, or trainees, take the time to remind them that their actions, both in the real world and the virtual world, have the potential for consequences.  Let them know their job interview doesn’t just begin when they walk through the door of a potential employer…it begins right now.

1. Informed consent: The concept of informed consent has its roots in multiple fields, but in medicine, informed consent was not a formal concept until the middle of the 20th century.  Respect for the values of others’ is paramount in patient care, and informed concept is at the heart of ensuring free will in medicine.
2. Randomized controlled trials (RCTs):  Although clinical trials themselves date back to the 1700′s with a trial of citrus fruits for scurvy, the specifics of RCTs as we know them today developed much more recently.  Concepts such as randomization, masking (better known as blinding), and concealed allocation are important elements of controlled trials that all had to be introduced into clinical research in the last few decades.  Before RCTs, clinical research was based on case reports of physicians’ experiences in managing certain diseases.  RCTs are now the mainstay of establishing best practice and treatments in medicine.
3. Intensive Care Units (ICUs): Bjorn Ibsen established the first ICU in Copenhagen in 1953.  The first ICU in the US was established at Dartmouth two years later.  Technological advances in medicine have often stemmed from ICU care, such as automated monitoring of vital signs and heart rhythms.  We can thank such advances for significantly contributing to improving mortality in critically ill patients.
4. Electronic charting: Yes, there are problems with electronic medical records. Yes, the “copy-and-paste” phenomenon is unbearable.  But as we incorporate more and more digital record keeping, order entry, and prescription writing into our daily lives, the less likely patients are to suffer because of the illegible handwriting that physicians have been famous for.
5. Specialty service and ancillary support teams: Teams comprising nurses, social workers, speech therapists, etc., are taking exponentially greater roles in providing excellence in patient care across the spectrum of healthcare settings.  Teams such as Wound, Ostomy, and Continence Nurse teams help ensure that patients receive consistent, reliable expert care and teaching when they require it.
6. The ACGME competencies: Last but not least, I thought I would mention a recent change in medical education.  The competencies have been developed in an attempt to standardize the outcomes in our education and training of medical students and trainees.  One long-term goal of the competencies is to ensure that physicians can do more than just take care of diseases; we need to be able to take care of patients in complex health-care systems with a patient-centric approach, and prove to our patients and payers that we do it well.

I am not saying that the current healthcare system is perfect.  It has a lot of pieces that need smart people to work together to fix.  But let’s at least be thankful for what we have.  What else are you thankful for in modern medicine?

I work at an academic medical center.  My patient base is quite different from that of a typical gastroenterologist in that I often get asked to consult on (i.e. render an opinion about treatment for) patients by other gastroenterologists.  Because I see patients from all over the state, patients often come from several hours away and do not expect to get their routine GI care where I work.  Patients frequently return to their referring gastroenterologist for their care after I have rendered my opinion or helped them through their situations.  This is the way tertiary care medicine is supposed to be.  When a patient returns to their gastroenterologist, they are closing the circle of the consultation.

How then should I feel when a referring physician sends me a note on a patient, originally sent to me by him, that says something to the effect of:

“John Doe is being seen in consultation at the request of Dr. Ryan Madanick for a history of colon polyps.” ?

Here are my issues with this:

1. I didn’t send the patient to him in consultation. I know how to take care of patients with a history of colon polyps. As a matter of fact, I DO perform colonoscopy. The patient returned to his care because he was the patient’s referring doctor in the first place, not because I wasn’t certain about the best option for this patient’s care.
2. The patient is returning to the original referring physician.  The visit shouldn’t even be billed as a New Patient Visit.  It is an Established Patient Visit (which pays a lot less).
3. If the patient’s insurance covers Consultation codes at a higher billing level, we are all losing (well, except for the payee). The patient probably wouldn’t see any difference. However, if this happens time and time again, the payment system would break down (or wait, maybe it already did…)

Let’s get this straight.  I know the referring doctor well, and I think he practices good medicine.  Still, we know why the note was documented this way.  And this is exactly the type of fraudulent billing practice that got the Consultation codes removed by Medicare.

I’ll end by making a plea:  Please don’t bill a patient and their insurance for a consultation when it is just a visit.

With all of the talk about the lack of generalists in medicine and waning interest in Internal Medicine, I only expected about 20 or 30 students to show up.  Instead, I arrived to see about 150 or so students with a nearly-completely filled auditorium.

What should I attribute this to?

I found out later that it was the first of the “Career Opportunity Series” luncheons for the new first year medical students.  That might be a good reason.

I’d like to think that there was some other great reason for so many students showing up.  Maybe they all really want to go into IM (or at least think they do at this juncture). Maybe they heard that I was going to be on the panel (yeah, right!).

Maybe they are truly “undifferentiated” and are taking every opportunity they can to figure out the right career choice for them (the “idealist” viewpoint”)…

Or maybe it was just the free pizza.

With that in mind, here are a few of the things I’ve learned in my first 6 months as a medical professional in Social Media:

1. Getting involved in Social Media means starting small:  Remember that “a journey of a thousand miles begins with a single step.”  How did I start?  Quite simply by writing a blog post about what I thought the blog would be about.  Although the focus and intent of the blog has changed somewhat, my experience grew out of that first simple piece.  
2. It is easy to feel overwhelmed in Social Media: Take a look at some of the established blogs and sites.  Depending on where you land, you might see some very advanced networking capabilities, extensive archives, and even advertisements.  But just like your career, if you are trying to build credentials and influence in Social Media, it will take time to grow.  Don’t be afraid of exploring and being led by some of the more seasoned medical bloggers.  You can learn a lot from them, and I continue to be amazed at the complexity of some of their sites.
3. “If you post it, they will come”: One of the most common things I hear people say (and one of the things that I said before I started blogging and tweeting) is that no one will see their blog, post, tweet, page, etc.  As I quickly learned, it doesn’t matter how many people you know now.  The more you get involved, the more your voice will grow.  We are still early in the intersection of Healthcare and Social Media.  All you really need now is an interest to be involved. When I wrote my second blog post about my friend’s personal experience undergoing endoscopy, I didn’t know who would see it or read it.  So I posted it to my own personal Facebook site.  I’m not even sure if I tweeted it or not, or who saw it the week I originally posted it.  Nonetheless since then my blog has had over 4000 views and my Twitter account has somehow picked up over 1000 followers.  And even though I posted that blog back in January, it became a permanent part of my blog archive, and there have been views of it even this past week.
4. Both the compliments and the criticisms come more quickly:  Traditional publishing takes months, even years to happen.  Those of us who occasionally or frequently write in medical journals or textbooks often get little public feedback, except for the occasional “Letter to the Editor”.  When criticisms do come in print, they are usually phrased in such a manner that professional relationships and standards can be maintained.  However in Social Media spheres, “peer review” is more like a “public review” of your topic or opinion by anyone who comes across it: peers, patients, or anyone who reads your post. Comments can be supportive, opposing, or even frankly inflammatory.  The ease of posting anonymously makes such opportunities for hateful scorn even simpler.  And for some the negative commentary can be just too overwhelming.
5. Venturing into Social Media is great way to communicate with a broad audience:  There are so many people with whom we can communicate.  It might be with your colleagues across the country, the general public, even your patients.  For those of my patients who seem interested, I give them the URL of my blog and let them know that I blog about various topics they might find interesting.  In doing so, I hope to become a real person to my patients, seen as someone with whom they can continue a dialog in the office, beyond just being a specialist in a white coat.  But it is important to beware of the risks of having private or semi-private discussions in a public forum, as such inadvertent mistakes can have dramatic consequences, even in “private” media like Facebook.
6. Don’t enter Social Media expecting to become wildly successful: There are very few prominent bloggers who make their livings (or a second living) by maintaining active blogs.  The experience in Social Media is one of engagement.  The more people you communicate with, the more people you will communicate with, as your voice grows.  Some people are good enough to be able to drum up extra business by posting great content and developing a strong “brand”.  But if your intended audience sees that you are just trying to promote your business or practice, you will lose the interest of many of the people you would hope to become your intended audience.
7. The proliferation of Social Media is not a passing fad: Whether or not you personally like it, “Social Media” is here to stay.  The popular Social Media sites and types may change from year to year, but this is the new reality.  As our patient bases grow more adept at using Social Media, those who do will expect similarly out of their doctors.  The same goes for the students, the trainees, and eventually our colleagues.  If we do not lead the way, we will trail behind those who do.
8. Getting involved in Social Media is not for everyone: Well, you probably saw this one coming.  When I originally wrote this piece, this was my #1 thing learned, but I think it works just as well here.  Clearly there are some docs who are drawn to Social Media and some who spurn it.  For the latter group, no explanations will get them to embrace newer methods of mass communication.  There is however another group, a diverse group that contains the majority of docs who are out there (if you are reading this and have not yet tested the waters yourself, this is you).  The group comprises those who are unsure or skeptical about using Social Media as well as those who might be interested but just aren’t sure what to do.  Bryan Vartabedian (33charts.com) asserts that physicians are obligated to participate in Social Media (although this view is not espoused by everyone).  Right now, there is no requirement to be involved in Social Media, but the later a doc gets involved, the farther behind the 8-ball and more antiquated the doc risks becoming.

“Mrs. Smith is a very pleasant 54-year old woman who…”

Why does this bother me, you might ask?

1. It immediately imparts a connotation in the note that this patient’s symptoms are to be “believed”, as opposed to other, less “pleasant” patients.  The doc is probably going to be more inclined to help this patient.  I explained to one trainee that I thought it should be changed in her future notes, and I explained why.  Her explanation was that it was a “code” for her to remember that the patient was easier to deal with than many other patients she often sees in her practice.  You can imagine how I took to that explanation…
2. It implies that other patients are less pleasant.  This same trainee uses “very pleasant” and “pleasant” in various notes.  I sometimes wonder what it means if she doesn’t put either in the note.
3. A patient’s consultation or progress note, and for that matter, the opening sentence in such a note, is not meant to be where a doctor imparts their values and judgments on the patient.  Pleasantness (or perceived pleasantness) is really the patient’s affect.  Therefore this descriptor really belongs best in the exam, if anywhere at all.

Other words are similarly inappropiate in this context; the word that most frequently comes to mind is “unfortunate”.

“Mrs. Smith is an unfortunate 54-year old woman…”

Although it may seem that you are empathizing with the patient, I doubt that a patient would want to actually see a doctor write in their note that they are “unfortunate”.  The consequence of their problems may be unfortunate, but not the patient him or herself.

By no means do I intend to say that this issue is confined to trainees; I see the same descriptions among seasoned physicians.  My best explanation for this is that no one really ever went over their notes, or that they were just never told to change it.  If you find yourself saying this is your own notes, ask yourself why…and consider omitting it next time.

Below is the brief backstory…if you’re interested in what happened.  Please read the poem first.

This was a poem I wrote the night after I experienced my first perforation during endoscopy.  The patient did not speak English, undergoing an ERCP for stent placement because of advanced pancreatic cancer obstructing the bile ducts. I was a fellow at the time (this was many years ago now); I was so distraught about it that I felt the need to go home and write this poem.

So I looked it up, just to be sure I was doing my due diligence.  If you aren’t aware of the possible side effects of licorice root, the major ones to be aware of are:

• Edema/fluid retention
• High blood pressure
• Potassium loss
• Headache

Fortunately, these only tend to occur at large doses (> 3 grams per day for several weeks) when the licorice root contains glycyrrhizin. In short, I thought it was fine for her since she was otherwise in good health, and the dose was not that large.

Nonetheless, there is an important reminder here: just because something is natural, doesn’t mean it is completely without side effects.  Even natural substances are still chemicals.

If you are a patient, please discuss all of your supplements with your physicians.  In this case in particular, extreme use can actually cause rare life threatening problems.  If you are a doctor or other healthcare professional, be sure to ask your patients about any herbs and supplements they might be taking.