ABC's for ECP's Scott Selinger

This is Scott Selinger and welcome to another fantastic jabbering edition of - ABC’s for ECP’s, the podcast on behalf of the Northern California’s chapter of the American College of Physicians Council of Early Career Physicians. To those most loyal of followers, you’ll notice it’s been a number of months since there’s been any movement with this podcast due to a combination of work, extracurriculars, and a new baby, but I am making an early new years resolution to more regularly get these up, up and away.  Let’s put a pin in the idea of new years resolutions too because I want to come back to that. There was a recent research letter in JAMA that set off a few ideas downstream for me.  The letter was dubbed “Time of Day and the Decision to Prescribe Antibiotics.”  Now just reading that title, my reaction and that of most people I’ve talked to about this was “well of course antibiotic prescribing goes up as the day wears on.” To summarize a little bit, the study looked at outpatient encounters for a number of upper respiratory infections through coding review, some of which are cases where antibiotics are sometimes indicated (i.e. sinusitis, otitis, strep pharyngitis) and others where they are never indicated (i.e. acute bronchitis, non-strep pharyngitis) in patients with NO comorbidities or other indications to receive antibiotics.  There were a number of more subtle findings but the answer did end up looking like yes, the amount of antibiotics prescribed, whether for conditions indicated or not, did increase as both the morning and afternoon clinic shifts wore on.   This sounds like an expected result, but why?  The study talked about the idea of decision fatigue, meaning the more decisions you have to make, the more you start looking for the easiest solutions.  Think about when you get a survey to fill out - do you spend as much time and thoughtfulness on the first answer as you do the tenth?  For most of us, no, we don’t.  And the translation for this is the otherwise healthy, mildly sick patient coming in asking for a z-pack for their cold.  If it’s 9am and you just finished your coffee, you have a lot more energy in you to talk with them about the lack of efficacy and risk of side effects than you do when it’s 5:30, you’re worrying about traffic on the ride home, you have some loose ends to follow up on from the rest of the day, and you’re just physically and mentally tired.  And those are the people more likely to get inappropriate antibiotics.   This letter pointed to an idea from The Psychology Bulletin comparing the mind’s self-regulation and self-control to a muscle - the more you use it, the more fatigued it gets.  This idea that you have a set amount of self-control to use throughout the day is certainly something to think about.  When you’re running a marathon, you make sure to take in some water at set intervals and sometimes slow down and walk so you can make it to the finish line.  But most of us don’t necessarily get to have those breaks when we need them - usually that’s the busiest part of our day.   And I don’t think this is necessarily something limited to the outpatient world.  Admissions also seem to go up as the day wears on in most places along with more decisions to make about workup and treatment (addendum: I was just guessing at this at first but it was hard to find data to back this - a VA study showed about 51% of patients visiting between 5 pm and 1 am were admitted, but also said this was contrary to national findings. The only real data I could find from the CDC (see below) showed an uptick in the afternoons but pretty steady admissions from about 10 am to 10 pm).  At the end of a shift, are you more likely to order a CT scan than at the start of the day?  What about admitting someone who could potentially be sent home?  What about dealing with calls from the wards?   Looping back around to New Years resolutions, is this the sam

This is Scott Selinger and welcome to another edge-of-your-seat-amazing talking blogpost - ABC’s for ECP’s, the podcast on behalf of the Northern California’s chapter of the American College of Physicians Council of Early Career Physicians.  Today I’d like to talk a little bit about this new world of patient satisfaction scores. I really like my new car.  I got it a few months ago and it’s been working great.  But then a few weeks ago I folded the back seat down and now it won’t come back up.  So like most men, I hit it a few times and then decided to take it to the dealership.  It was a pretty easy, seamless process of getting in and out but there were a few snags.   For instance, they told me I needed a new part and they’d call when they got it in - but that didn’t happen and when I called 2 weeks later I found out that the part I needed had been there for 10 days.   And then there was the little issue of the fact that when I got the car home, the seat was still broken.  I brought it back, saw a different service advisor, who apologized profusely, and they got it fixed the same day.   The kicker was, every time I was there, I was reminded before I left that “by the way you might be getting a survey …” at which point I cut them off and just gave them a thumbs up and said “all 5’s guys!” because I really wasn’t interested in hearing the spiel – the surveys they send out are based on top box scoring, so if they get anything except a 5 out of 5, they get dinged, even if they had nothing to do with the dissatisfying issue. This is getting to my main point about patient satisfaction surveys and its effect on us as physicians.  This is something I slowly started hearing more about towards the end of residency, but at the time the satisfaction scores at the resident clinic were abysmal and we felt sort of resigned to that because a lot of the dissatisfying factors were systems issues beyond our control.  That’s if you can imagine patients being dissatisfied by frequently seeing random doctors, long wait times, bedside manners that were still under construction, and frequently being told that they didn’t need antibiotics for their cold or opioid pain medications for their headache.  But now that I’m out practicing, I’m realizing how huge an issue this is.  I’m still trying to figure out when someone needs steroids and when they need antibiotics or the best way to convince them they need to quit smoking or lose weight and honestly, sometimes this weighs on my mind especially when I have someone demanding something I know is unreasonable.   With all the money that is tied to patient satisfaction scores between Medicare reimbursements based on it as well as organizations and practitioners trying to maintain patient loyalty and the insurance money that comes along with it, it’s no wonder it frequently feels like our profession is starting to more resemble that of the service industry, but saddled with the complexities of human health.  To tie back to the car problem I had, a colleague of a colleague now routinely, in her follow up emails to her patients, has a little tagline at the bottom talking about what they should do if they get a survey!  Patient satisfaction scores are now commonly being tied to physician pay and advancement or retention at their current job, the theory being to incentivize us to make that extra effort to make sure our patients are satisfied by their medical care. And in theory this sounds great because why shouldn’t patients have an exceptional experience every time?  Why should they expect any different of us than they do of their mechanics (and I don’t mean to pick on mechanics - I’m just still a little miffed at mine).  Well, there may be a few reasons, just because our profession is a little different than many others in the service industry. A study[1] just published a few weeks ago in the Journal of Patient Preferences and Adherence (wh

Normal 0 false false false EN-US JA X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; line-height:115%; mso-pagination:widow-orphan; font-size:11.0pt; mso-bidi-font-size:10.0pt; font-family:Arial; color:black;} This is Scott Selinger and welcome to another scintillating episode (webisode? pod? I’m not totally sure what to call these serial casts) any way, it’s another ABC’s for ECP’s, the podcast on behalf of the Northern California’s chapter of the American College of Physicians Council of Early Career Physicians.  As I’ve got a wedding to head to in beautiful scenic St. Louis this weekend flanked by a trip to the national ACP meeting in Orlando next week, I’ll make this a  brief one.  We’ve all heard about mindfulness and mindful meditation, and it sounds great in theory, but how do we bring it into our daily practice?  Is there actually a way in our hectic shift schedules to find time for a calming experience?  I think so, and I’ve been starting to do it. Deep breathing exercises are a great relaxation technique.  The NIH’s National Center for Complementary and Alternative Medicine has noted research supporting the power of relaxation techniques on improving control of numerous medical and psychiatric conditions, or to put it a way we more commonly hear it, “Side effects of relaxation techniques may include improved control of anxiety, depression, asthma, fibromyalgia, headaches, chronic pain, angina, hypertension, insomnia, IBS, nausea, TMJ syndrome, tinnitus, and overactive bladder.”  Sounds pretty good right?  If only we had a time when we could incorporate it into our daily practice … But fear not!  There is a way!  The next time you’re getting ready to perform an auscultation as part of your respiratory exam, give this a try: put your hand on your patient’s shoulder, your stethoscope on their chest, ask them to take some deep slow breaths through their mouths, and then breathe along with them.  This can help you out in a few ways: 1)  Firstly, if you’re breathing along with them, you’ll be able to make sure they aren’t hyperventilating to the point they might pass out by the end of the exam (as I’ve seen a few overeager patients do) 2)  Second, as mentioned above, for the patient with any of the conditions mentioned above, the act of deep breathing may help put them more at ease in their interaction with you.  They may feel less anxious, their pain may be a little diminished, their blood pressure may go down a little bit and if they do get any of these benefits, you will have just illustrated a safe, effective, free, non-pharmacologic treatment that they can take home with them 3) Finally, looking at your own wellness and all the stress and external stimuli we’re bombarded with in our daily practice, it can help give YOU a moment of calmness and clarity, probably making you spend a few extra seconds on auscultation, and let you both come out on the other side of the exam feeling a little more at ease and connected as you get ready to discuss the assessment and plan. Personally I can say that I’ve been trying this for the last few months and in the midst of seeing 11 or 12 patients every 4 hours, it has been a little oasis of respite so I definitely encourage you to give it a shot with your next patient.             Additionally, I want to give another little plug for mini meditation sessions to make your day easier.  Search for “how to meditate in a minute” and you’ll find a nice, short, animated cartoon that will talk about the benefits of meditation and show you how quickly you can see them if you can find just a minute in your busy day.  It’s a cartoon and it’s about 5 minutes long and I think it

Howdy - This Scott Selinger and welcome to the podcast on behalf of the Northern California's chapter of the American College of Physicians Council of Early Career Physicians.  I should note that I'm thinking about calling the podcast ABCs for ECPs, ECP's being early career physicians.  It seemed a little more legit than the original working title, modeled after my favorite phrase to hear from a patient, "Can I be real with you?"   One of my biggest concerns starting off my medical career, is staying up to date.  Through medical school and residency, it seemed like so much time was devoted to learning about new practice altering information because I was always trying to catch up with and impress my attendings with things they hadn't heard of.  At the end of residency, I think I was subscribed to at least 10 different journals and newsletters, on top of the e-newsletters and listservs, and trying to peruse through all of them is just something I felt I had to do every week.  I was always searching for that one little nugget of information that would make life better and easier for my patients and for myself.   But now I'm out, and I'm practicing in a busy setting and having trouble to find the time to do as much reading and research.  But I still feel that need, that pressure, to stay up to date on all the breaking evidence.  Now of course we're required to have our continuing medical education and doing things to fulfill our ABIM maintenance of certification requirements, but that's not my real driving force.  I'm sure we've all seen patients either coming into the hospital or transferring to a new clinic on a bizarre outdated medication regimen.  And my fear is ultimately becoming one of those physicians.   While there's not a fantastic amount of high quality data out there, a systematic review published in the Annals of Internal Medicine about 10 years ago, looked at 62 studies regarding various outcomes relative to physicians years of practice.  Almost 75 percent of these studies showed decreasing guideline adherence in a variety of performance and outcome measures with increasing years of experience, and that scares me a little bit.  Now I'm sure like all studies there's geographic and practice setting variance, but overall it makes sense that the more entrenched you get into the everyday world of patient care, the harder it is to be able to step back and access your own practice and the advancing practices of those around you.   To put it more simply I feel like I'm Rocky in Rocky III.  I've come from being a little nothing to an attending physician.  I've knocked out Apollo Creed twice, med school and then again in residency and know I'm riding high and taking pictures and even doing pod casts.  But I know somewhere out there it's Clubber Lang, some new kid on the block or some new piece of data that's hungry, and slowly working its way up the chain, and if I don't do enough to stay on top of my game I'm gonna get knocked out.  So what is an early career physician to do?  Well to help get some guidance I spoke with Dr.  Gurpreet Dhaliwal, a clinician educator and associate professor in clinical medicine at UCSF who has particular interest in medical education and clinical and diagnostic performance and improvement.   Me:  Doctor Dhaliwal thanks so much for joining me today.  So I guess to dive right in, what mistakes do you feel physicians make starting out; as far as what they try to do with staying up to date with all the recent advances, and new papers and things like that. GD:  I'm thinking it's hard to make a mistake in terms of trying to stay up to date.  But just doing that itself is a good effort.  It's a commitment to lifelong learning.  I think one of the mistakes that might be made is that thinking the best way you're gonna do service to yourself and your patient is keeping up with all the new studies that are coming out.  A lot of the new studies are alluring and inter

This is Scott Selinger and welcome to the first podcast on behalf of the Northern California’s chapter of the American College of Physicians Council of Early Career Physicians.  Given that this is our inaugural podcast, I thought it’d be a good time to talk about introductions - how you enter into that first meeting with a new patient and how you handle the name game. Before I’ve done pretty much anything new in life, be it starting 6th grade, a new job, interviews, whatever - I’ve gotten a call from my dad where he just says: “remember first impressions.”  While this started out as rhetoric I would roll my eyes at, it’s become very important in my role as a physician, as I’m sure it has for every doctor out there.  That moment where you meet a patient for the first time is paramount in establishing trust and setting the tone of the rest of your relationship with them. One thing that I’ve found is more important now, especially given how busy we all are in cold and flu season, is taking a moment to ready yourself before meeting that new patient.  We have so many other things are mind is on during the day - returning that page or email or message, following up on a lab, getting out on time - that it’s easy to let that ruin your first impression, your tone of voice, and your body language.  It’s crucial that your new patient knows that the only thing you’re thinking about while you’re talking to them is them.  Of course that can’t always be the case, but more and more I’ve found how helpful it can be before opening that door or pulling back that curtain, to stop, take a deep breath, put on a little smile, and focus on forging a great new doctor-patient relationship. But then how do we introduce ourselves?  It’s probably a lot easier in the outpatient setting because by the time someone arrives in your office, they usually know who you are (and in many cases may have read a little blurb about you as well).  In the hospital, it’s a much more difficult setting - the new patient may not know why they are there (or even who they are), they may have already seen numerous other doctors and healthcare workers and have lost track of names, and they usually don’t know what every doctors’ role is (and why should they?).   In both settings, it’s important that you clarify what your role is in their care.  It could be “I’ll be handling your day to day medical care and coordinating with our specialists, if needed” or “I’m here to talk with you a little about what’s been going on and start you on the path to getting better and then one of my colleagues will meet with you in the morning to check in and help guide your care from there” or “I’m here to be your go-to person for any aches, pains, rashes, coughs and colds that pop up and keep you as healthy as I can.”  This is important and often overlooked as the last thing you want is to be finishing up your encounter and hear something like “so when is my doctor getting here?” Now what’s in a name?  How do you introduce yourself to your patients?  Some people introduce themself as Dr. Smith, others as Dr. Adrian Smith, and still others just say Adrian Smith and then clarify their status as a doctor and their role.  I’ve found that people are pretty divided on this and a lot of it seems to come from where they trained as the east coast (and even the south coast where I trained) has a much more formal atmosphere in general than here on the west coast and I think that plays into what style of introduction you use.   What I was taught, and I think most people had this same training, is that your patient should be addressed as Mr. or Ms. and you introduce yourself as doctor so-and-so.  I can’t count how many training videos for patient interactions I’ve seen that start this exact way.  But is this ideal in today’s world or is this part of the outdated paternalistic model of the patient-physician relationship?

I'm Scott Selinger, American College of physicians member, native Texan, but current Californian and fairly early career physician.  Having just finished my chief residency in internal medicine in mid- 2013 and practicing as a primary care physician since then I'm getting the ball rolling on this podcast on behalf of the Northern California ACPs Council of Early Career Physicians for a few reasons.   First and foremost, we felt that it can be a sounding board for musings specific to all the early career physicians out there by which we mean anybody in their first sixteen years of practice after medical school.   Secondly, we wanted it to be a way for the Northern California ACP members and early career physicians to communicate a little about what's going on in their practice.  Given the nature of medicine today and the other commitments we all have, we have a tendency to isolate and practice on our own little island unless we make efforts otherwise.  Our hope is that this podcast can succinctly address some of these issues that we've seen in our own practice and we'd love to hear about what's going on in yours, so we can direct future podcasts in that direction.   Finally, we like to use this as a part of a growing multimedia effort to get the early career physicians of Northern California a little more united and universally aware of some of the things going on with our local group and help colleagues network a little more easily.   Now While I truly do enjoy the sound of my own voice and thereby assume everybody else does as well, we're going to try to keep these on the short side - something you can listen to on the drive to work at the gym, walking the dog or whatever you have time to fit it in.  We also hope to be able to include interviews with some of our leading ACP fellows, Governors, Masters and other leaders about their take on some of these issues.   We look forward to broadcasting for you, with you and about you and stay tuned for the first installment.  If you have any burning questions or comments you can e-mail them to canocecp@gmail.com or head on over to our Facebook page for the Northern California chapter of the ACP Council of early career physicians, seek and find out more about the events going on.