One last graduation

Graduations are always memorable.
I still remember my elementary school graduation, where I received a special award. It was a Thesaurus and Webster's hardcover dictionary. For a skinny little brown kid who recently moved back from Bangladesh, this was an incredible moment.

High School. College. Medical School, Residency.
And now one last graduation.

I just completed an 16 month fellowship here at Stony Brook School of Medicine titled "Leader's in Medical Education." It's a course designed to give us the knowledge and tools to prepare us as future leaders and educators in Medicine.

It was a wonderful enriching course that I never expected to take. A few years ago, near the end of the my residency when I was deciding what to do, "Leadership" and " Medical Education" were the last things on my mind. Medical school and Residency had left me skeptical, cynical and in debt. I simply wanted to work and take care of my family. I really had no direction or long term goals with my career.

Fast forward 5 years, everything has changed (except the debt of course!). There have been many twists and turns to this point in my career. Ultimately, I feel quite fortunate to be where I am, having completed this course with some terrific colleagues.
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Although this was the smallest graduation I've been apart of, it's possibly the most important. For the first time, after graduating, I think I can finally comfortably answer this question.

What do you want to be when you grow up?

And with that, now it's finally time to really get to work!


Here's our class photo!
I'm the one on the top row, far right!

Here's a shot of my poster for our final project. I'll write a post about this, hopefully soon

Gone but not forgotten

Haven't written for a while.
But this blog is not forgotten.

Just a lot on the plate lately.

Here's what I at least plan on writing on in subsequent blog posts


1: A general summary of my experience at ACP 2013.
Here's a summary of a different type. A collection of my tweets on Storify.

http://storify.com/ShabbirHossain/acp-2013-san-francisco

2: Recently completed a survey study on our medical students here at Stony Brook University School of Medicine looking at social media use. The goal of the study was to gauge the students' opinions on social media's potential advantages and disadvantages for collaborative (group) learning.
There were some very interesting findings which I'll definitely share here.

3: As always, there are interesting, inspiring stories to share from the patient care side of things.
Every patient is a potential incredible story.
 
4: My interest in digital health  has not weaned. I'm working on new collaborations with folks from different disciplines and expertise to bring innovation in medicine. This is a process and experience that will be worth discussing

5: For the first time, I've gotten involved with basic sciences curriculum development. Our medical school has begun the daunting task of completely reforming the 1st and 2nd year curriculum. It's fascinating to hear what the basic science students want and are concerned about. As a clinician and patient advocate, it's imperative that I (and other clinicians too) advocate for tools, experiences and skills that lead our students to become complete physicians. Despite the many excellent physicians we are producing, the traditional curriculum is not good enough.This is a multi-year process so I definitely plan to share this experience too.

6: We're also starting a health literacy study in our resident clinic. Health Literacy is a major problem and barrier to making our interventions work. Hopefully, we come out with some good solutions that I can share here

7: Finally, as we look to July and our new interns, I'm in the process of implementing a weekly curriculum for our residents to help develop a different set of skills necessary to thrive in the Electronic Medical Record (EMR) era of medicine. Our young physicians are growing up learning a style of medicine that doesn't always translate well into themodern practice.

So a lot going on, but I feel truly fortunate to be in a position to participate in so much.

Also a quick shout out to my family.

Despite everything going on, it's always about them.
Without them, there really is nothing. :-)

A busy day, a hectic week, a crazy month.
Feeling Good

2 viral infections, 2 different outcomes

In the course of 3 days (last month), I saw 2 patients that presented with the exact same viral illness.

Mild sore throat, fatigue, subjective fevers, dry cough.

In both patients I suspected a viral infection that didn't require an antibiotic.
That's where the similarities ended.

Patient A was a 60+ year old male with a few stable medical problems who regularly came to our resident clinic. I saw him with our residents a few times before. She stated she get's this once a year and antibiotics always resolved it. When I suggested just symptomatic treatment and time, the visit turned sour. His wife who was also in the room, questioned the entire visit, suggesting I was making him suffer. The wife's doctor (from a different office) had already started her on antibiotics for a similar illness. It was a Friday and I promised I would call him Monday to reassess symptoms.

I called Monday, and  he said he was feeling a bit better, but had already gone to an urgent care center Sunday and received antibiotics.

"Sigh." I thought.

Patient B was a 50 year old male, and presented with essentially the same illness. I gave the same viral illness speech and offered the same follow-up call.

"you got it Doc!" 
And with a smile, he was off.

The difference?

Patient B 2 years prior, walked into our office with 3rd degree heart block.
 He credits us (and his cardiologists!) for saving his life that day.

A patient requesting antibiotics for a viral illness is a common event in primary care and can cause quite a bit of "agita" 

 I also know how hard it can be to say no to a patient.
I also know how in primary care, the amount of time we get with a patient really limits proper counseling.

Ultimately, it's a trust issue. Trust between a patient and primary care physician is a core principle that takes time to develop. I don't always have the luxury of rescuing a patient from the jaws of death and getting instant credibility. It takes a lot of time, effort, patience and counseling to develop a trustworthy relationship.

Unfortunately, in modern medicine, many elements undermine that trust. Until primary care physicians are given the opportunity and incentive to do what it takes to that build trust, our healthcare system will continue to erode and free fall further into the abyss.

Follow the bouncing DVT

This is about the fragmentation of our health care system
This is about accountability.
This is about a man, with limited transportation and a bad set of knees.

Mr. Pinball (name changed) is 80+ years old. A wonderful guy who unfortunately was diagnosed with an unnamed cancer . Fortunately, it was surgically resectable, and his surgeon did an incredible job of removing it, with no complication. I couldn't be happier for him.

Several days after surgery, while recuperating at home, he noticed worsening leg swelling. Because of his history of congestive heart failure, Mr. Pinball was worried he was retaining fluid (especially since his water pills were held around the time of surgery.) He called his cardiologist, who didn't think this was related to his heart. Instead he was advised  to contact the surgeon to be evaluated for a potential post operative complication like a DVT (deep vein thrombosis) i.e. a blood clot in the leg.

Dutifully, Mr. Pinball called his surgeon who also reiterated a similar concern for a DVT. He was advised by his surgeon to contact his primary care physician (me) to get evaluated for a DVT by getting an ultra sound.

 Mr. Pinball called us and I advised him to immediately come in for a look. He was able to come in to our office, thanks to a caring neighbor. Mr. Pinball, no longer drives.

Our suspicion for a DVT was high, so we quickly obtained the  necessary imaging, and he had what everyone expected. On a side note, he had to take a taxi home from the radiology office that night, because his neighbor left. For an elderly gentleman on a fixed income, a 30 dollar cab ride hits hard.

From his initial concern to our office visit, 5 days had elapsed. 5 days of bouncing around without anyone informing him of the potential seriousness of a DVT. Between doctors giving him the run around, and social circumstances limiting his ability to access healthcare, something bad could have happened.

Fortunately, nothing bad happened. Mr. Pinball is doing fine. But how many Mr. Pinball's are out there, victims of a fragmented healthcare system that has misaligned incentives and poor accountability?

How many Mr. Pinball's aren't being saved by the safety net of primary care that is stretched to its limits?

Step down therapy

 Insurance companies will list certain drugs as "ST" or step up therapy. A patient needs to fail the formulary alternatives before "Stepping up" to a medication that isn't covered.

I've been practicing a lot of "Step down" therapy, and here's why.

With the recent economic turmoil and high unemployment rates, we've seen many patients in difficult financial circumstances. Many patients have lost their employer based commercial insurance plans and switched to Medicaid. Unfortunately, many providers in our community don't take Medicaid and they end up switching care to our resident continuity clinic. This influx of patients (formerly with commercial insurance) has given me additional perspective on our healthcare system.

One of the first things we have to do with such patients is review their medication list and make changes. Most of the managed Medicaid companies have strict formularies and will not cover many brand name medications. Initially, my initial reaction was frustration. As a patient advocate, I want the power to give patients medications that I feel is appropriate, especially if they have a track record of success.

But once I began to peel away the layers of such cases here's what I found.

I've seen several patients on brand name medications that had never tried generic alternatives. Some were never offered it, and some showed aversion to generics, stating they never worked as well. When I asked them how they ended up on a specific therapy, several had indicated it started out with samples in their doctor's office. And once it was established that these brand name samples worked, nothing else was offered.

I also recall a patient who was dropped from their commercial insurance plan because he seeked overpriced out of network care at a place notorious from practicing what I would classify as fringe concierge medicine.

Shockingly, we had a patient on a brand name proton pump inhibitor, paying 75 dollars a month and never offered any of the myriad of generic options. He couldn't have been more thrilled at the opportunity to try something much cheaper.

This is a just small skewed sampling of issues I have seen. The vast majority of such cases have great positive outcomes that meet the expectations of both physician and patient.

It think it's great that our healthcare system provides choices for patients. That flexibility is a strength. But it comes at a price. The price is care that is subject to becoming bloated, overpriced and not evidence based.

My hope is that the medical community can continue to build trust with our patients and show them that cost effective care is just as good. What may be looked at as "step down" therapy is really a "step up" for the patient, physician and healthcare system at large.



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Medicine is a biologic AND social science

 I'm embarrassed to admit but I had cliched notions of why I wanted to be a doctor in my formative teenage years. Get ready to cringe folks.

" I want to help people! "
" I love science! " 

I decided to major in Biology as an undergraduate because I believed medicine was primarily about biology.
I did the bare minimum liberal arts courses as an 18 and 19 year old. A little bit of economics, a little bit of European history, a little bit of English and a little bit of philosophy. I didn't take any courses in law, ethics, psychology and anthropology. I didn't appreciate its value and moved on to medical school with the goal of helping people, utilizing my expertise in this biologic science.

Despite medical school and residency programs' feeble attempts at educating trainees on taking care of the "whole" patient,  most young doctors today cling to the notion that medicine is primarily a biologic science.This is despite the fact that we have young doctors with many different degrees and backgrounds. I've seen this manifest in many ways.

I've spoken to many medical students to ascertain some of the motivations behind their impending career choices. Many choose careers in surgical specialties because of their love of the surgery itself and its hands on approach to managing disease. I've had students tell me they've pursued certain career paths because they are more comfortable in fields that put less emphasis on patient contact. Even in my own field of Internal Medicine, students seem to love the academic discussion on disease diagnosis and management. No matter what field they choose, there seems to always be an underlying appreciation for the life science aspect of disease.

With post-graduate trainees (residents) the story is similar. Many are choosing sub specialty fields because of their appreciation for the specific subset of diseases they get to manage. Even those staying in internal medicine, are largely choosing hospitalist careers for many reasons including an interest in managing the acutely ill. I've come to the conclusion, a common fundamental thread in career decision making is that same trite statement and assumption I started my own career with; " I love science. "

But medicine is not just a biologic science. The concept of treating the "whole patient" simply means medicine  is both a biologic and social science. But our training and attitudes don't reflect that. I often hear students and residents mention an aversion to the "social " issues of a patient. It has become largely acceptable for specialists to let hospitalists and primary care physicians handle the "social" issues. Even hospitalists will sometimes defer social issues to their outpatient counterparts.

This cynic will look at this and call it "dumping." No matter the perspective, neglecting the social sciences aspect of patient care is simply incomplete bad medicine.

How do we change this?
For starters, we need to change the image of medicine as a field for life science lovers. We need people that also love the human aspect of disease.

 Secondly, we need to value social sciences education when we assess potential for medical school.  I think we are already trying to do this. But despite our subjective efforts to  identify well rounded students, the objective admission criteria is weighted heavily towards basic sciences grades and MCATS.

Thirdly, medical schools need to incorporate the social sciences in their curriculum to further augment skills to be a complete physician. I would even advocate for more flexible curriculums that allow medical students to get dual degrees such as an MD + (JD or MBA or MPH).   This would also be the pipeline where all our physician leaders would eventually come from.

 Finally, education in post graduate training  needs to emphasize the importance of a patient's social situation and how it relates to clinical outcomes. Concept's like the " Patient Centered Medical Home" and "Team Based Care" utilize concepts from the social sciences to improve the way healthcare is delivered. Residencies need to teach this, and accreditation bodies should look for expertise in such things before giving the green light to practice medicine independently.

I realize I'm advocating for something I didn't have. It just means instead of doing the usual Internal Medicine CME stuff, I'll be getting in touch with my liberal arts side to continue to become a better physician.

Addendum.
New York Med, Non traditional path to medicine

The hardest thing in Medicine today

I can't imagine how difficult it was to practice medicine in the "dark ages". I would feel helpless.

In the pre-antibiotics era, I can't imagine how difficult it was to care for a patient with an infection.  Without rapid high fidelity imaging, I wouldn't know how to manage patients with acute abdomens, strokes and many other conditions. 

There's a lot modern medicine affords us that we take for granted. With relative ease, I can prescribe potent antibiotics and order expensive imaging without putting much thought into it. Such cavalier "easy" medicine would seem unfathomable to our physician forefathers and our current colleagues who struggle caring for patients in the 3rd world. 

Recently, in our office one of our bright conscientious resident physicians discussed a case about an elderly demented patient whom he suspected had pneumonia.  He wasn't sure the patient had pneumonia because the history and physical exam wasn't convincing. Because the patient was frail and elderly, and the diagnosis was uncertain, he wanted to send him to the hospital for further diagnostics, monitoring and management. An ER visit would guarantee blood work, imaging, IV antibiotics, an admission to our medical service and more importantly a clear conscious. In my opinion this was the easy way out. 

After discussing a few academic issues related to risk benefit ratio of the different ways we could have managed this case and also taking into account patient and family preference, we decided to send the patient home with an attempt to manage him as an outpatient. 

I explained to the resident, who is extremely intelligent, compassionate but also lacked confidence (understandable for a trainee) the easiest thing in medicine today, is to do. It's very easy to do anything or everything. But he didn't go through years of education and training, to make easy decisions. As doctors we are counted on to help make the difficult decisions. In modern medicine, the difficult decisions are not related to what we can or should do. The hardest thing in medicine today is the decision to do less, or sometimes nothing at all. 

A discussion on behavior change ( Part I )

I had a very interesting discussion with a frustrated resident. After dealing with a difficult patient with multiple chronic diseases, he expressed frustration about patients that don't follow through with our recommendations. He took a big step in identifying some of the problems in how we counsel patients. 

 When we see a patient we are quick (and good) at pointing out all the bad things that could happen if a behavior change isn't adopted. 

   ”If we don't do a better job controlling your diabetes, X, Y and Z could happen." 

This is what our current training in medicine advocates. Our education revolves around the diseased state, how to treat it, how to cure it and to a lesser degree, how to prevent it. And when we talk about prevention, the motivation is based on what the physician values. In this case the physician values the”X, Y & Z" outcomes, but patients may not put as much stock in that. 

The resident suggested shifting motivation to what the patient values. 

  “If we do a better job controlling your diabetes, you will feel better." 

“If we do a better job controlling your diabetes, you are more likely to make it to your grandson's wedding."

This was terrific insight from a young, inexperienced doctor. And with that, he touched on one of the sentinel questions in modern medicine. What is the best way to enact behavior change in medicine?

There are several elements to it. The most fundamental prerequisite is to know your patients well and what they value. By understanding what they value, we can tailor behavioral change advice that is meaningful on a personal level and therefore more likely to succeed. This is a fundamental concept in how we should be practicing medicine. It is also a concept we don't emphasize enough in medical school and residency training. 

My discussion with the resident carried on much further. In subsequent parts, I'll share some of the  technical aspects of behavior change that we discussed and how to incorporate it in modern medicine. 

A patient centered medical home for our residents

We are in the process of setting up a patient centered medical home(PCMH) for our internal medicine resident continuity clinic. For the longest time, the PCMH seemed like a nebulous concept for me. If someone asked me what it was, I'd have a difficult explaining it. But after spending time reading the literature, I have a better idea . But now that we're building it for our residents, we have to explain it to them. This can always be a challenge, especially when the PCMH redefines how we deliver care. Residents are already used to doing things a certain way, and concepts that require behavior change and extra effort can sometimes be a tough sell (for trainees and patients for that matter).

In patient care, it's easy to get caught up in the details. I often advocate that the residents take a step back, and give the patient a big picture perspective. This is my big picture perspective on the PCMH.

It's starts with the notion that the way we practice medicine isn't very good. Considering, how much money we invest in healthcare, most metrics indicate we don't get nearly as much for our healthcare dollars as many other nations do.

I liken our health care system to a custom made exotic car. It's expensive. It's got components of all the great cars. You take the best parts of a Ferrari, Aston Martin, Porsche, Mercedes. Lamborghini, Bugatti, you've got our health care system. It's potential is incredible. Despite it being an incredibly powerful machine, it is limited by one crucial factor. It is the driver. We have terrible drivers.

And that's what I want the PCMH to be for our resident trainees.. It's driving school. It's learning a new and better way to drive this car. It's learning about how all the custom made components work together. It's about making each patient's journey in this vehicle a better one. It's simply about delivering better care.

A wolf in the sheep's pasture

We had a lawyer giving medical grand rounds today.
It had a malpractice flavor to it. It was about some of the medico legal pitfalls with our adoption of an electronic medical record (EMR).

Normally, the doctors are the sheep sitting in the courtroom den and the lawyers playing the part of the wolf. It was the reverse today.

I'm going to stay true to my promise to be succinct. (I could rant a lot about today's talk. Some of it is on twitter!)

There wasn't any substance to the talk. It was basically "be careful of this " , "don't do that " , "you have to be able to defend this."

Ultimately, the verdict was this. Despite the EMR being a major advance in how we provide care (my opinion), it's opened up a myriad of holes that our legal system can take advantage of to find fault in our care for patients.

I can cite numerous examples of how ridiculous this train of thought is. I can identify the hypocrisy in many of the examples this lawyer cited. But I'm not building a case. Perhaps if I was a lawyer, I could create an elegant argument against today's grand rounds in the hopes of changing the minds of the powers that be.

I'm just a doctor.
I'm just a primary care physician.
I don't have time to be a lawyer. I'm too busy taking care of sick people.

I can only only operate within the confines of our legal system. I can only continue to advocate for a future of medicine that is not constrained by our legal system and continues to leverage technology to improve the health care system.