The Orthopedic Posterous

RULE 1A: Physicians should embrace Rules 1B-6 because WE ARE ALL PATIENTS !!! 

Rule 1B: They don’t want to be at your office.

It may seem odd to patients, but most doctors forget that going to the doctor is generally unnerving. We work there, and being in a doctor’s office is normal to us. Not so with most patients. The spotlight is on them and their health. They stand on the scale, undress, tell intimate things about their lives, confess errors, are poked, prodded, shot with needles, lectured at, and then billed for the whole thing….There is always an underlying fear and self-consciousness that pervades when a person is sitting on the exam table. The best thing to do in response to that is to show compassion.

Rule 2: They have a reason to be at your office.

They don’t come to the office to waste the doctor’s time. Yet early in my training I was incredulous at the reasons some of my patients were coming to see the doctor. Why come in for a headache? Why come in for a cold?…It took me being in my own practice (and trying to keep my business going) to realize that there is (almost) always an underlying reason for a patient to come in. Sometimes that reason is simple: they have terrible pain that needs to be treated. Other times, however, the reason is more subtle. When a person comes to my office with enlarged lymph nodes, for example, the real reason they are coming in is that they are afraid it is cancer. If a person has chest pains, they are afraid it is their heart. On every visit I try to identify the real reason (or the real fear) that brings them to see me. I don’t end the visit until I have addressed that reason.

Rule 3: They feel what they feel.

Patients will often tell me their symptoms in a very apologetic tone. They seem to think that they have to come to me with the “right” set of symptoms, and not having those symptoms is their fault. Sometimes those symptoms make no sense to me at all, and I am tempted to dismiss or ignore them. But as a physician, you have to trust your patient….Yes, some may exaggerate what they feel out of anxiety or out of fear that you won’t hear them for lesser symptoms, but then your job is to uncover the anxiety, not ignore the complaint. I have heard from many patients that their doctor “did not believe” their complaints because they did not make sense. If you don’t trust them, why should they trust you?

Rule 4: They don’t want to look stupid.

People are often worried that they are over-reacting. They wonder what I must think for a person to come to the office with that symptom. This is especially true of parents bringing their children in. Nobody wants to be “that mother that over-reacts to everything.” In response to this, I try to specifically say, “I am glad you came to the office for this because…” or “Yeah, I can see how that worried you because it could be….”

Rule 5: They pay for a plan.

What do people pay for when they come to the medical office? They pay for opinion, yes. They pay for knowledge as well. But what they really pay for is a plan of action….They want to know what is going to be done to help. I try and give a plan, either verbal or written, to each patient that walks out of the exam room. What medications are given and why? What medications are to be stopped? What tests are ordered and what will the results mean? When is the next appointment? What should they call for if they have problems? The better I can answer these questions, the more confidently the patient will walk out of the exam room. The days of paternalistic medicine are over - no handing a prescription and just saying “take it.” Patients should know why they are putting things in their body.

Rule 6: The visit is about them.

With all of the stresses in a doctor’s office, I get tempted to complain about things. Who better to complain to than someone who feels much the same way? But patients are paying for you to take care of their problems, not the reverse. I keep my personal gripes or frustrations to myself as much as possible.

Dr. Robs' rules, initially published in NYT and on his blog in 2008 deserve to resurface in the blogoshpere every now and then.

Consent is not the goal. Consent is an outcome. It should be the outcome of an informed choice process, which probably takes more than one conversation and which requires decision support of some sort.  We don’t think this is often achieved and yet its likely that patients would value this and that litigation rates would fall. That would be a significant cost reduction in most systems.

I want to thank those of you who pointed me towards the bigdecisions.net blog, started a few weeks ago by a *colleague* in the UK.

This is such an important concept. Defining each patient's values, lifestyle, needs, goals, and risk aversion are necessary in order to determine whether a contemplated treatment or care plan is *appropriate*. This Informed Choice concept is not *new*, but it is gaining a little more traction thanks to the participatory medicine e-patient movement and a few committed physicians... I will be following this blog and suggest you do too.

Until the arrogance of the IT industry is recognized and countered - even if it comes, in a quasi-comical suggestion, to the doctors arming themselves with scalpels and cutting every network cable in sight - and it is recognized that experiments conducted under false assumptions are doomed to fail - our approaches to health IT, per the National Research Council, will remain insufficent [10].

The latter organization recommended that health IT success will depend upon accelerating interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering.

This research will be a long time in coming if we as a society are still at the level of arguing about whether "health IT is harder than it looks" and about the unproven and arrogant assertion, made with a straight face by process re-engineering analysts and consultants seeing money to be made, that the computer will achieve miracles only when we "change medical processes" [i.e., adjust medicine, the occupee, for the convenience of medicine's occupiers, the IT industry].

*In reality, handwriting issues aside, there is little wrong with "the old medical chart" from an information science perspective. It evolved over a century or longer to serve the needs of its users. It is a simple document in terms of organization, containing sometimes complex information but in an easy to find form (when maintained by humans properly) and in a presentation style that recognizes human cognitive limitations in very busy, complex social environments such as patient care settings*

What would an EMR from Google or Apple look like?!?!? I doubt we'll ever know... but imagine the simplicity, elegance and connectivity.

It is a challenge faced by many athletes, coaches, and anyone else who has committed to living as a vegetarian. Unless you are versed in nutrient metabolism, you may find the myriad of information regarding this topic a bit discouraging and conflicting.

How do you start? The first step is to check the source and date of information and to review more than one website on any given topic. Also read the reviews from people in the various health care fields. Reviews of a study from a naturopath or homeopath may take one side, a professional from integrated medicine may report another approach, fact, or opinion. And traditional or conventional medical practitioners may have a different opinion, fact, or research study results to report. How do you put it all together to make a wise choice?

Good points in this short article. But *popular* doesn't always mean *accurate*. As the author points out... always vet the source, source your information from multiple sites and in time you will find the sites which typically have information that is timely, relevant, hopefully *unbiased* and most of all helpful and actionable !

Wave is NOT appropriate for an EHR/EMR platform. Formal health records should be based on standards such as ISO 18308 – ‘Requirements for an Electronic Health Record Reference Architecture’ and ISO/DTR 20514 – ‘Electronic Health Record Definition, Scope and Context’

Until the third party engineers and programmers get cracking and expose the true usefulness of the g-wave platform we can not answer this question. But follow the link... there are some great points made about potential uses.

When Americans go looking for information on health, they turn to the Internet as one of their first sources. According to a recent survey by the Pew Internet and American Life Project, 61 percent of adults say they look online for health information. There's a term for them: e-patients.

Most e-patients go online to read about a health condition. But that seems almost passive compared to the way a small group of Internet-savvy people are connecting to get their health information.

About 20 percent of e-patients go to Internet and social-networking sites where they can talk to medical experts and other patients, says Susannah Fox, with the Pew Internet and American Life Project.

Patients are going online, patients are engaged and collaborating in pursuit of *quality* health care information.

The physician community needs to engage WITH these patients...eyes wide open--- as a team leader. We need to engage to help filter the noise--- and aid in minimizing the risk of information overload or analysis paralysis.... and perhaps even the physician will learn a thing or two. Different patients have different needs --- different patients have differing abilities to synthesize the information and make the *right* choice.

How should the physician engage with these communities?

How can you help me to help you ??