Febrifuge

Spam aside, it’s interesting to see this old thread come up. How is everyone feeling NOW about telemedicine? Me, I’ve had a few recently where it’s clearly not the best option, but for example this morning my patient either has biceps tendinitis or maybe some shoulder arthropathy. In the clinic, I could do some passive ROM maneuvers and feel for the crepitus or any clunking, sure. But video is good enough for checking some key active ROM and ruling out quite a few possibilities. And the plan is the plan regardless, at least for now. I rather doubt that we will ever get back to seeing 100% of these issues in the clinic, and there will be at least a few patients asking “can we just do this by video?” at least to start with. And I do believe I’m okay with that.

Yeah, I am not at all interested in leaving. When the world isn’t upside-down, this is the best team I’ve ever been part of. It’s just, nowhere is safe, y’know? It was naive to assume that being salaried would insulate us from the revenue/ RVU bullshit, but I had been hanging on to a little of that feeling.

I’m finding myself struggling with some unexpected, complicated emotions. Our group is nominally a not-for-profit, and we’re both a health system and a health insurance plan. The effect is that since revenue is way down, it sounds like we’re at serious risk. The CEO announced that she is (and presumably others in the C-suite are) taking a 40% pay cut. They announced that first. 15 minutes later, I learned that everyone in our division will be asked to take a 30% pay cut. Our MDs and PAs are salaried, so the math is easy. People elsewhere in our part of the org who are on RVUs will be paid at 70% of their 2019 average. This will be in place for 4 months, and then we’ll see. I mean, I guess it *sounds* fair, and it’s better than a lot of what I’m reading here. But, ouch. I spent a lot of years poor, and took out all the loans to change careers. I’m nearly as old as friends who have been practicing for twice as long. I never thought of myself as being obsessed with money, but not gonna lie, this sucks. Feels that the only choices are a) to go along with the idea that my labor is now worth less than it would be if the rest of the org were doing elective surgeries and over-ordering tests, or whatever, or b) accept that I’m being under-paid but there’s no option other than grin and bear it, or get furloughed with no idea of a return date.

I'm on Humira - when I had my cancer scare, I was taken off it, and within a few months I had one of my severe flares, the kind I've had just a few times in the 30-ish years since I was diagnosed, and in the 18 or so years I've been on biologics. So stopping is arguably my least favorite option. But my health system has done some re-organizing and planning, and I feel pretty well protected. Patients are assessed on the phone first, and in the past week or so we have done everything possible to move scheduled office visits over to phone visits. Visitors and patients entering the building are asked all the screening questions first. People with respiratory symptoms are directed to a specific subset of our Urgent Cares, for either scheduled or walk-in visits. People with no respiratory symptoms can use the rest of the UC locations. Last week on Monday, I saw 8 patients in the office plus 12 on the phone. Yesterday it was just one pre-op, for a surgery that can't be postponed, and the rest were phone. We still have the option of asking a patient to come in if there's something we need to assess in person, and if they have no respiratory symptoms, but even those are being treated as high-risk. I know there's debate and sometimes strong opinions about telemedicine, but right now is a good time to lean on your history-taking skills and clinical judgment. As a good Oslerian, I consider the physical exam a way to confirm what I think I know, or find out what I know I definitely don't know yet, based on the history. If something needs to be done in person, I have a process for getting it done. But yeah, in a situation where I was seeing undifferentiated patients, some of whom had obvious COVID-19 symptoms, hell no I wouldn't accept that without a lot of discussion and planning.

Some observations, point by points starting with your opening line: This really doesn’t seem like a general question. This seems very specific. 1. If you’re saying you are not familiar with how research about admissions criteria compared to academic performance is done, and you’re wondering how a program director can design and implement a study about which measures best predict student performance in an academic setting, there are qualified people who participate on these boards who can help break it down. But I don’t think you’re asking that. It sounds like you’re starting from the premise that something inappropriate is happening and you’re asking for validation of that. 2. This doesn’t sound to me like an ethics question. So I think the most constructive and useful way to go forward would be to ask you this: please describe what you see as the ethical problems, and why you consider them to be so, and then the group can weigh in on some specific questions. Thanks. Looking forward to a good discussion.

Show me someone who claims they never make mistakes, and I'll show you someone who is lousy at recognizing their own mistakes. The trick is to embrace your mistakes. There are few more effective or memorable lessons. Do what you can to make them small, make them correctable, and make them once each. I only worry about people who keep making the same kind of mistake repeatedly; that's a failure to learn, and that's less okay.

I have several really well tuned, carefully written patient info sheets that give the big picture and then go into detail about how no, green doesn't mean bacteria (myeloperoxidase is cool!) or that if you've been sick for a day and a half and you're draining thin clear stuff, you don't have a bacterial sinus infection. But I get good mileage just saying "I mean, the thing is, if I gave you antibiotics today, then you'd have this cold, plus diarrhea, and no real benefit to show for it." Similar approach for people who think they need a chest x-ray: "today's Thursday. You've been sick since Monday. I think you sound just fine, you don't have a fever, and your saturation is 100%. If you roar back into your usual good health over the weekend, we would have done an x-ray today for no good reason. If you feel worse next week and it seems like a good idea to get an x-ray then, I'd really feel better about ordering it if it's not your second one in 10 days, y'know?" People appreciate knowing that I have a thought process. I cheerfully acknowledge that I'm open to the idea I might be wrong, and in fact it seems to disarm them to find I'm not just some a-hole insisting I must be right. That's followed with the idea that dammit I'm advocating for your health, even if you're not getting what you think you wanted. I'm not going to cause you problems with side effects or unnecessary radiation because I was being a chicken about it. People get confused. They sometimes pause, like they know they're supposed to be upset, but they feel cared for and listened to. They seem to kind of admire the way I just denied them without making them feel dumb (because they also suddenly understand they were being dumb). It's a cool thing to see, when it comes together.

Family history is not a risk factor under the ACC guidelines. Neither is low socioeconomic status. Are you trying to study actual practice patterns, or how well people know and follow the evidence-based recommendations?

If you want to be blunt, think of it this way: somewhere out there is someone who graduated the same year as you, maybe even someone from your program, who is WAY more stupid and unprepared than you are. And yet, this hypothetical person isn't tying him- or herself in knots and questioning everything. He/she is sailing along, doing their best, learning as they go, and gradually getting better. The question is, do you want to give up, and let this chucklehead actually become smarter and better than you, or do you want to figure out how to proceed? The impostor syndrome is real, and nobody is perfectly able to identify where they're at on the Dunning-Kruger curve. The fact that you're worried is probably good, but worrying isn't all that helpful. Talk to a mentor, and if you don't have one, please get one. Get a bunch, if you can.

We do a fair proportion of phone visits- but those are to check in with our established patients. If the entire purpose of a visit is to have a conversation about "so how is the losartan/ citalopram/ metoprolol working out?" then making the patient take half a day off from work and deal with our parking ramp is not only not indicated, it's bordering on mean. If they have anything whatsoever that we might feel should be looked at, listened to, or palpated, then we have no hesitation about asking patients to come in for an office visit. But 15 minutes on the phone is often actually a better way to learn about how it's going, when the patient is relaxed and receptive.

Functionally, our group works as a team, and we all sign for each other. We also question one another and verify or clarify as needed. If I get a request to refill something and I don't like what I think I'm seeing, I am expected to ask about it, consult with whoever else is there that day, and decide what to do based on my own judgement. If I told one of the docs, even my SP of record, "I just signed it because I thought you would expect me to," they would look at me funny. I'm not an extender or an assistant; I'm one of the clinicians on this team.

I just wish people wouldn't be sent to us because someone read a PPD as "positive" when there was less than 10mm of redness and no induration whatsoever. A truly positive skin test can literally be read with your eyes closed, right?

Okay, but the question - and the thing you need to plan around - is what do you do with the people you don't approve? Are you going to allow for "determination pending" and re-visits within 45 days? If you don't have support staff and a facility to be part of, mind your logistics and prepare for the unlikely weird stuff, is my advice.

I am also gradually working on a way to talk about this stuff with patients. Lately there's been some progress using the analogy of lawn care and gardening. I had someone tell me they "never use chemicals" on their lawn, and then turn around and suggest that for taking care of some weeds we have in ours, we use white vinegar. I said LOL that's acetic acid, which is a chemical you chucklehead, and we laughed about it, the friend agreeing with me, but saying you know, there's a difference. And I think that's it: there are chemicals we think we know well, and feel okay about, and don't think of as "chemicals," and then there's everything else. It's about comfort. It's not about effectiveness. My friend also said to be careful not to get the white vinegar on any plants I don't want to see dead. Compare that to some of the organic chem nonsense in the appropriate aisle at Home Depot, with long weird names and the ability to kill broad-leaf plants but have no effect on grass. Not sure yet how to put it all together, but if the goal is educating and getting people to think, I find the indirect approach is often good.

Good point: my group defines full-time as 35 hours a week of scheduled patient visits. It's understood there can be about an hour a day of random charting, dealing with emails, paperwork, etc. Sometimes more, sometimes less, averaging out to 5 hours a week so a work week is really about 40 hours. We don't get scheduled for 40 hours in front of patients and then told to just deal with the rest.