Jeff Susman, MD

I was making the 2-hour trip from our annual Ohio Academy of Family Physicians meeting in Columbus back home to Cincinnati. I calculated carefully and I would only have to detour a half-hour. I told myself it really wasn’t out of the way. And after all, it would be a treat for everyone. Well, we all have our petty rationalizations. But I’ll always detour for delicatessen.

As I reflected on my motivations, and the reasons why pastrami, corned beef, and other heart-healthy alternatives such as half-done Kosher dills were perfectly appropriate additions to my diet—not to mention the rugelah (a tempting pastry full of cream cheese, confectioner’s sugar, and fruit filling)—I stepped into the deli and began a journey reaching back well over a century.

Walking into a delicatessen is like revisiting family gatherings at my grandparents—the rye breads and challah, gefilte fish and herring, knishes and kugel. I recall long-dead relatives and simpler times when a long meal with a vast collection of cousins and family was routine. Maybe our lives were slower-paced. I guess it is why we have big Sunday dinners on a regular basis.

As I hoisted a bag brimming with the makings of a first-class spread, I had a pang of guilt. What will my family physician do when he sees my elevated blood pressure or wonders how my sugars have been? I guess I’ll just have to blame it on nostalgia and trying to recapture a bit of my past.

The wise family physician understands. One of the “50 Years in Medicine” honorees at our state academy meeting captured this wisdom well. After a busy week of house calls and ministering to the sick, he was dog-tired and only wanted to take a well-deserved nap. In an effort to divert his son, the doctor took a magazine ad and cut it up to serve as a puzzle. Satisfied that this diversion would allow a deep and restful slumber, he was surprised to be awoken only 10 minutes later.

When the doctor asked how he had put together the puzzle so quickly, his son replied it was easy. The opposite side had a picture of a person in the center, and once you had the picture of the person, it was easy to fill in the rest of the pieces. It’s like that with family medicine. Once you know the whole person and his family, it’s easy to put the rest of the pieces together.

Now, excuse me while I have a hot pastrami sandwich.

I was making the 2-hour trip from our annual Ohio Academy of Family Physicians meeting in Columbus back home to Cincinnati. I calculated carefully and I would only have to detour a half-hour. I told myself it really wasn’t out of the way. And after all, it would be a treat for everyone. Well, we all have our petty rationalizations. But I’ll always detour for delicatessen.

As I reflected on my motivations, and the reasons why pastrami, corned beef, and other heart-healthy alternatives such as half-done Kosher dills were perfectly appropriate additions to my diet—not to mention the rugelah (a tempting pastry full of cream cheese, confectioner’s sugar, and fruit filling)—I stepped into the deli and began a journey reaching back well over a century.

Walking into a delicatessen is like revisiting family gatherings at my grandparents—the rye breads and challah, gefilte fish and herring, knishes and kugel. I recall long-dead relatives and simpler times when a long meal with a vast collection of cousins and family was routine. Maybe our lives were slower-paced. I guess it is why we have big Sunday dinners on a regular basis.

As I hoisted a bag brimming with the makings of a first-class spread, I had a pang of guilt. What will my family physician do when he sees my elevated blood pressure or wonders how my sugars have been? I guess I’ll just have to blame it on nostalgia and trying to recapture a bit of my past.

The wise family physician understands. One of the “50 Years in Medicine” honorees at our state academy meeting captured this wisdom well. After a busy week of house calls and ministering to the sick, he was dog-tired and only wanted to take a well-deserved nap. In an effort to divert his son, the doctor took a magazine ad and cut it up to serve as a puzzle. Satisfied that this diversion would allow a deep and restful slumber, he was surprised to be awoken only 10 minutes later.

When the doctor asked how he had put together the puzzle so quickly, his son replied it was easy. The opposite side had a picture of a person in the center, and once you had the picture of the person, it was easy to fill in the rest of the pieces. It’s like that with family medicine. Once you know the whole person and his family, it’s easy to put the rest of the pieces together.

Now, excuse me while I have a hot pastrami sandwich.

I was making the 2-hour trip from our annual Ohio Academy of Family Physicians meeting in Columbus back home to Cincinnati. I calculated carefully and I would only have to detour a half-hour. I told myself it really wasn’t out of the way. And after all, it would be a treat for everyone. Well, we all have our petty rationalizations. But I’ll always detour for delicatessen.

As I reflected on my motivations, and the reasons why pastrami, corned beef, and other heart-healthy alternatives such as half-done Kosher dills were perfectly appropriate additions to my diet—not to mention the rugelah (a tempting pastry full of cream cheese, confectioner’s sugar, and fruit filling)—I stepped into the deli and began a journey reaching back well over a century.

Walking into a delicatessen is like revisiting family gatherings at my grandparents—the rye breads and challah, gefilte fish and herring, knishes and kugel. I recall long-dead relatives and simpler times when a long meal with a vast collection of cousins and family was routine. Maybe our lives were slower-paced. I guess it is why we have big Sunday dinners on a regular basis.

As I hoisted a bag brimming with the makings of a first-class spread, I had a pang of guilt. What will my family physician do when he sees my elevated blood pressure or wonders how my sugars have been? I guess I’ll just have to blame it on nostalgia and trying to recapture a bit of my past.

The wise family physician understands. One of the “50 Years in Medicine” honorees at our state academy meeting captured this wisdom well. After a busy week of house calls and ministering to the sick, he was dog-tired and only wanted to take a well-deserved nap. In an effort to divert his son, the doctor took a magazine ad and cut it up to serve as a puzzle. Satisfied that this diversion would allow a deep and restful slumber, he was surprised to be awoken only 10 minutes later.

When the doctor asked how he had put together the puzzle so quickly, his son replied it was easy. The opposite side had a picture of a person in the center, and once you had the picture of the person, it was easy to fill in the rest of the pieces. It’s like that with family medicine. Once you know the whole person and his family, it’s easy to put the rest of the pieces together.

Now, excuse me while I have a hot pastrami sandwich.

It was my third phone call after registering and re-registering to no avail at the “customer-friendly” web site. There was the usual 15 minutes on hold and the transfers to endless voice mail options, none of which applied to my situation. Was I trying to secure a rebate coupon on my latest purchase? Upgrade my Windows software? Validate that lifetime rust-proofing on my car? Nope. Simply trying to refill my prescriptions.

Like many of you, I prefer to renew my prescriptions online, by phone, or by mail. And as I get older, I acquire chronic problems—minor conditions like diabetes and hypertension—that necessitate regular prescription renewals.

Well into the third hour of investigation, I was hot on the trail of my medication renewals. Now, if I could only remember which pet’s name I gave (Gabby? Mouser? Rasha?) and the unique combination of at least 5 numbers, 3 letters, and a punctuation mark (not including “-’s”), I’d be all set. Let’s see, I wrote those double-super-secret passwords on that file card and placed it on my desk somewhere…

Finally, success—well, almost. There was the obligatory physician reauthorization, even though he had renewed this script only 4 months ago. And of course, that Humalog is a secondtier medication (maybe I should use purified pork insulin?).

OK, you get the picture.

It is no wonder many patients fail to renew their medications even once. It is no surprise our patients fail to achieve goals for the treatment of diabetes and hypertension. Instead of enabling health, we continue to assure patients have countless barriers placed in their paths. It is almost as if insurers and pharmacy benefit managers are making sure we don’t use our benefits.

So here are a few simple practical suggestions for purveyors of medications. When your web site changes, why don’t you notify your users of the new web address? Why not assure that the phone number on the back of our insurance cards gets us a live person who can provide useful information? How about allowing physicians to determine the length of renewal rather than making arbitrary decisions; and, after receiving initial approval, assume medications are needed on an ongoing basis. And at your web site, in addition to posting arcane prescription numbers, why don’t you make it possible to simply check a straight-forward description of medications for renewal?

It’s time physicians and other health professionals take a stand against such chicanery.

It was my third phone call after registering and re-registering to no avail at the “customer-friendly” web site. There was the usual 15 minutes on hold and the transfers to endless voice mail options, none of which applied to my situation. Was I trying to secure a rebate coupon on my latest purchase? Upgrade my Windows software? Validate that lifetime rust-proofing on my car? Nope. Simply trying to refill my prescriptions.

Like many of you, I prefer to renew my prescriptions online, by phone, or by mail. And as I get older, I acquire chronic problems—minor conditions like diabetes and hypertension—that necessitate regular prescription renewals.

Well into the third hour of investigation, I was hot on the trail of my medication renewals. Now, if I could only remember which pet’s name I gave (Gabby? Mouser? Rasha?) and the unique combination of at least 5 numbers, 3 letters, and a punctuation mark (not including “-’s”), I’d be all set. Let’s see, I wrote those double-super-secret passwords on that file card and placed it on my desk somewhere…

Finally, success—well, almost. There was the obligatory physician reauthorization, even though he had renewed this script only 4 months ago. And of course, that Humalog is a secondtier medication (maybe I should use purified pork insulin?).

OK, you get the picture.

It is no wonder many patients fail to renew their medications even once. It is no surprise our patients fail to achieve goals for the treatment of diabetes and hypertension. Instead of enabling health, we continue to assure patients have countless barriers placed in their paths. It is almost as if insurers and pharmacy benefit managers are making sure we don’t use our benefits.

So here are a few simple practical suggestions for purveyors of medications. When your web site changes, why don’t you notify your users of the new web address? Why not assure that the phone number on the back of our insurance cards gets us a live person who can provide useful information? How about allowing physicians to determine the length of renewal rather than making arbitrary decisions; and, after receiving initial approval, assume medications are needed on an ongoing basis. And at your web site, in addition to posting arcane prescription numbers, why don’t you make it possible to simply check a straight-forward description of medications for renewal?

It’s time physicians and other health professionals take a stand against such chicanery.

It was my third phone call after registering and re-registering to no avail at the “customer-friendly” web site. There was the usual 15 minutes on hold and the transfers to endless voice mail options, none of which applied to my situation. Was I trying to secure a rebate coupon on my latest purchase? Upgrade my Windows software? Validate that lifetime rust-proofing on my car? Nope. Simply trying to refill my prescriptions.

Like many of you, I prefer to renew my prescriptions online, by phone, or by mail. And as I get older, I acquire chronic problems—minor conditions like diabetes and hypertension—that necessitate regular prescription renewals.

Well into the third hour of investigation, I was hot on the trail of my medication renewals. Now, if I could only remember which pet’s name I gave (Gabby? Mouser? Rasha?) and the unique combination of at least 5 numbers, 3 letters, and a punctuation mark (not including “-’s”), I’d be all set. Let’s see, I wrote those double-super-secret passwords on that file card and placed it on my desk somewhere…

Finally, success—well, almost. There was the obligatory physician reauthorization, even though he had renewed this script only 4 months ago. And of course, that Humalog is a secondtier medication (maybe I should use purified pork insulin?).

OK, you get the picture.

It is no wonder many patients fail to renew their medications even once. It is no surprise our patients fail to achieve goals for the treatment of diabetes and hypertension. Instead of enabling health, we continue to assure patients have countless barriers placed in their paths. It is almost as if insurers and pharmacy benefit managers are making sure we don’t use our benefits.

So here are a few simple practical suggestions for purveyors of medications. When your web site changes, why don’t you notify your users of the new web address? Why not assure that the phone number on the back of our insurance cards gets us a live person who can provide useful information? How about allowing physicians to determine the length of renewal rather than making arbitrary decisions; and, after receiving initial approval, assume medications are needed on an ongoing basis. And at your web site, in addition to posting arcane prescription numbers, why don’t you make it possible to simply check a straight-forward description of medications for renewal?

It’s time physicians and other health professionals take a stand against such chicanery.

The epidemic began in a nondescript conference room in a Washington, DC hotel. A small group of physicians and clinical experts were the origin of this menace. While the inoculum was small and the exposure limited, this disease promises to spread quickly.

I should have known better. Each time I am exposed, I have that same queasiness; just thinking about it makes me break out in a cold sweat. I try to avoid worrying. Fortunately, I am recovering, even as the epidemic inalterably spreads.

You might already be exhibiting signs of this plague: the bleary eyes, the woeful frown, the haggard look. You are a victim of qualms—or quality measurement stress.

Your first exposure probably came from an envelope marked “PRIVATE,” or during a lunchtime meeting—or, if you were truly unfortunate, from a local medical director. At first, there was disbelief, bargaining—all of the Kübler-Ross stages. Eventually, you try to live life as before. Another qualms victim.

As I sat at the technical assistance panel considering over 40 quality measures, just in the area of mental health, I knew I had fallen victim to qualms again. All was lost when I reluctantly voted to approve yet another accountability measure that recommended screening. How many hours would I have to spend with each patient just to implement these measures? I break into that cold sweat, my pulse races….

Sure, the efficacy evidence is persuasive. Who can argue that depression or alcohol misuse is not important to find or treat, or that patients with depression shouldn’t be evaluated for bipolar disorder or drug abuse. But I only have 15 minutes. And there is a waiting room full of patients. And they all have so many problems. I imagine the worse….

The group of psychiatrists and specialists is cordial. They empathize. But, see, here is the evidence. It can be done. You can screen for depression and problem drinking and these treatments are efficacious.

But you don’t understand. I don’t stop at depression—there’s diabetes, dyspepsia and diarrhea, colonoscopy, contraception and colposcopy, holding hands and healing hearts. You can’t expect more. Every specialist wants me to screen for their disease; every panel implores me to treat their syndromes. I am over-whelmed….

“Next Measure: percentage of patients diagnosed with a new episode of depression and treated with antidepressant medication who had at least 3 follow-up contacts….”

I truly have qualms.

The epidemic began in a nondescript conference room in a Washington, DC hotel. A small group of physicians and clinical experts were the origin of this menace. While the inoculum was small and the exposure limited, this disease promises to spread quickly.

I should have known better. Each time I am exposed, I have that same queasiness; just thinking about it makes me break out in a cold sweat. I try to avoid worrying. Fortunately, I am recovering, even as the epidemic inalterably spreads.

You might already be exhibiting signs of this plague: the bleary eyes, the woeful frown, the haggard look. You are a victim of qualms—or quality measurement stress.

Your first exposure probably came from an envelope marked “PRIVATE,” or during a lunchtime meeting—or, if you were truly unfortunate, from a local medical director. At first, there was disbelief, bargaining—all of the Kübler-Ross stages. Eventually, you try to live life as before. Another qualms victim.

As I sat at the technical assistance panel considering over 40 quality measures, just in the area of mental health, I knew I had fallen victim to qualms again. All was lost when I reluctantly voted to approve yet another accountability measure that recommended screening. How many hours would I have to spend with each patient just to implement these measures? I break into that cold sweat, my pulse races….

Sure, the efficacy evidence is persuasive. Who can argue that depression or alcohol misuse is not important to find or treat, or that patients with depression shouldn’t be evaluated for bipolar disorder or drug abuse. But I only have 15 minutes. And there is a waiting room full of patients. And they all have so many problems. I imagine the worse….

The group of psychiatrists and specialists is cordial. They empathize. But, see, here is the evidence. It can be done. You can screen for depression and problem drinking and these treatments are efficacious.

But you don’t understand. I don’t stop at depression—there’s diabetes, dyspepsia and diarrhea, colonoscopy, contraception and colposcopy, holding hands and healing hearts. You can’t expect more. Every specialist wants me to screen for their disease; every panel implores me to treat their syndromes. I am over-whelmed….

“Next Measure: percentage of patients diagnosed with a new episode of depression and treated with antidepressant medication who had at least 3 follow-up contacts….”

I truly have qualms.

The epidemic began in a nondescript conference room in a Washington, DC hotel. A small group of physicians and clinical experts were the origin of this menace. While the inoculum was small and the exposure limited, this disease promises to spread quickly.

I should have known better. Each time I am exposed, I have that same queasiness; just thinking about it makes me break out in a cold sweat. I try to avoid worrying. Fortunately, I am recovering, even as the epidemic inalterably spreads.

You might already be exhibiting signs of this plague: the bleary eyes, the woeful frown, the haggard look. You are a victim of qualms—or quality measurement stress.

Your first exposure probably came from an envelope marked “PRIVATE,” or during a lunchtime meeting—or, if you were truly unfortunate, from a local medical director. At first, there was disbelief, bargaining—all of the Kübler-Ross stages. Eventually, you try to live life as before. Another qualms victim.

As I sat at the technical assistance panel considering over 40 quality measures, just in the area of mental health, I knew I had fallen victim to qualms again. All was lost when I reluctantly voted to approve yet another accountability measure that recommended screening. How many hours would I have to spend with each patient just to implement these measures? I break into that cold sweat, my pulse races….

Sure, the efficacy evidence is persuasive. Who can argue that depression or alcohol misuse is not important to find or treat, or that patients with depression shouldn’t be evaluated for bipolar disorder or drug abuse. But I only have 15 minutes. And there is a waiting room full of patients. And they all have so many problems. I imagine the worse….

The group of psychiatrists and specialists is cordial. They empathize. But, see, here is the evidence. It can be done. You can screen for depression and problem drinking and these treatments are efficacious.

But you don’t understand. I don’t stop at depression—there’s diabetes, dyspepsia and diarrhea, colonoscopy, contraception and colposcopy, holding hands and healing hearts. You can’t expect more. Every specialist wants me to screen for their disease; every panel implores me to treat their syndromes. I am over-whelmed….

“Next Measure: percentage of patients diagnosed with a new episode of depression and treated with antidepressant medication who had at least 3 follow-up contacts….”

I truly have qualms.

Mrs Jones was a regular patient in our residency practice who presented with a breast mass. After a failed aspiration attempt, one of our third-year residents appropriately noted the concerning nature of this mass and referred the patient to a surgeon for possible biopsy. A mammogram obtained at the time of referral was highly suspicious for cancer. Two years after presentation, our risk management staff informs us that Mrs Jones is filing a malpractice claim for our failure to diagnose her cancer. It seems the mammogram result was never seen by the surgeon and the patient was lost to follow-up.

Mrs Smith contacts the on-call physician complaining of pharyngitis and has classic symptoms of strep throat. Penicillin is prescribed. One half-hour later, the local pharmacist calls noting that Mrs Smith is allergic to penicillin.

Mr Brown has long-standing, treatment-resistant depression. He is prescribed a recently available SSRI. Three weeks later, his psychiatrist calls and chides, “What were you thinking? This patient is on a MAO-I and could have suffered a serious complication.” In reviewing his chart, you see no mention of the MAO-I and the most recent psychiatric note is from 3 years ago.

Maybe one of these real-life cases resonates with you. Perhaps you have had a similar experience. Or maybe you are thinking, “Not in my practice.” But one small study in family practice suggests that medical errors may occur in up to a quarter of our office visits.¹ While many of these errors do not result in significant harm or a malpractice claim, the Institute of Medicine claims, “patient safety is indistinguishable from the delivery of quality care.”²

To spotlight this important area, we will be publishing a series of cases in our Grand Rounds feature that highlight the importance of patient safety. We hope not only to lay bare common safety concerns but to provide you with practical approaches to preventing errors. Isn’t it time we prioritize improvement efforts on keeping our patients safe?

Mrs Jones was a regular patient in our residency practice who presented with a breast mass. After a failed aspiration attempt, one of our third-year residents appropriately noted the concerning nature of this mass and referred the patient to a surgeon for possible biopsy. A mammogram obtained at the time of referral was highly suspicious for cancer. Two years after presentation, our risk management staff informs us that Mrs Jones is filing a malpractice claim for our failure to diagnose her cancer. It seems the mammogram result was never seen by the surgeon and the patient was lost to follow-up.

Mrs Smith contacts the on-call physician complaining of pharyngitis and has classic symptoms of strep throat. Penicillin is prescribed. One half-hour later, the local pharmacist calls noting that Mrs Smith is allergic to penicillin.

Mr Brown has long-standing, treatment-resistant depression. He is prescribed a recently available SSRI. Three weeks later, his psychiatrist calls and chides, “What were you thinking? This patient is on a MAO-I and could have suffered a serious complication.” In reviewing his chart, you see no mention of the MAO-I and the most recent psychiatric note is from 3 years ago.

Maybe one of these real-life cases resonates with you. Perhaps you have had a similar experience. Or maybe you are thinking, “Not in my practice.” But one small study in family practice suggests that medical errors may occur in up to a quarter of our office visits.¹ While many of these errors do not result in significant harm or a malpractice claim, the Institute of Medicine claims, “patient safety is indistinguishable from the delivery of quality care.”²

To spotlight this important area, we will be publishing a series of cases in our Grand Rounds feature that highlight the importance of patient safety. We hope not only to lay bare common safety concerns but to provide you with practical approaches to preventing errors. Isn’t it time we prioritize improvement efforts on keeping our patients safe?

Mrs Jones was a regular patient in our residency practice who presented with a breast mass. After a failed aspiration attempt, one of our third-year residents appropriately noted the concerning nature of this mass and referred the patient to a surgeon for possible biopsy. A mammogram obtained at the time of referral was highly suspicious for cancer. Two years after presentation, our risk management staff informs us that Mrs Jones is filing a malpractice claim for our failure to diagnose her cancer. It seems the mammogram result was never seen by the surgeon and the patient was lost to follow-up.

Mrs Smith contacts the on-call physician complaining of pharyngitis and has classic symptoms of strep throat. Penicillin is prescribed. One half-hour later, the local pharmacist calls noting that Mrs Smith is allergic to penicillin.

Mr Brown has long-standing, treatment-resistant depression. He is prescribed a recently available SSRI. Three weeks later, his psychiatrist calls and chides, “What were you thinking? This patient is on a MAO-I and could have suffered a serious complication.” In reviewing his chart, you see no mention of the MAO-I and the most recent psychiatric note is from 3 years ago.

Maybe one of these real-life cases resonates with you. Perhaps you have had a similar experience. Or maybe you are thinking, “Not in my practice.” But one small study in family practice suggests that medical errors may occur in up to a quarter of our office visits.¹ While many of these errors do not result in significant harm or a malpractice claim, the Institute of Medicine claims, “patient safety is indistinguishable from the delivery of quality care.”²

To spotlight this important area, we will be publishing a series of cases in our Grand Rounds feature that highlight the importance of patient safety. We hope not only to lay bare common safety concerns but to provide you with practical approaches to preventing errors. Isn’t it time we prioritize improvement efforts on keeping our patients safe?

An overhead page interrupted my reverie; a usually placid nurse came running over: “Doctor, we have a problem.” Resuscitation was already started. The patient was blue and had no pulse. I began chest compressions as my colleague started to bag the patient and ACLS was initiated. A senior resident took over the chest compressions and I went over to talk to the family.

I silently reviewed what I knew about the family and patient, a mechanic who had begun to forget familiar things, like the alarm code at the car lot. He had come reluctantly to our office—his wife and daughter were concerned about Alzheimer’s disease. A picture of gradual memory impairment and increasing behavioral changes emerged. We discussed the prognosis, behavioral approaches, support groups, and treatment.

Following that initial encounter, I can’t remember when the issue of chest discomfort arose—the patient never complained to his family of chest pain. Like much of what happens in medicine, its discovery was a matter of routine diligence or dumb luck. At today’s visit, he had been free of discomfort over the last few days. He didn’t ascribe much significance to his vague symptoms.

His EKG, though, was not vague. I was surprised: “Good thing we checked.” We discussed options and settled on an urgent cardiology evaluation and a raft of medications. Death forestalled, the patient went into the restroom. When he hadn’t emerged in 5 minutes and wouldn’t respond to a knock, the door was unlocked and his body found on the floor.

“We are doing everything possible, but it doesn’t look good.” These words always sound hollow and insufficient when death calls unexpectedly. As the rescue squad rushed away, I gave directions to the daughter, knowing the small likelihood of a positive outcome. The expected news from the hospital came even before the frantic call from the family—they were lost, needed more directions. Better they receive bad news in person.

I spoke to the daughter the next day, and said how sorry I was—if only we had checked on him more quickly, summoned the ambulance sooner…. But the daughter was appreciative, guilty that she hadn’t divined her father’s problem sooner. I reassured her, provided my absolution, a liturgy of forgiveness.

She stopped in the office again the other day. She offered me a hug. “You lost your father too, recently?” Yes, but we had time to prepare. “It must be hard.”

Yes, death shouldn’t have the temerity to invade our office, our sanctuary. We talked about her mother, the reunion of family, the funeral. Death humbles us all; it is sad and sobering that the thread of life so thin. It is not only in the cure that good work is done, but during that bridge from life to death, and in ministering to those left living.

An overhead page interrupted my reverie; a usually placid nurse came running over: “Doctor, we have a problem.” Resuscitation was already started. The patient was blue and had no pulse. I began chest compressions as my colleague started to bag the patient and ACLS was initiated. A senior resident took over the chest compressions and I went over to talk to the family.

I silently reviewed what I knew about the family and patient, a mechanic who had begun to forget familiar things, like the alarm code at the car lot. He had come reluctantly to our office—his wife and daughter were concerned about Alzheimer’s disease. A picture of gradual memory impairment and increasing behavioral changes emerged. We discussed the prognosis, behavioral approaches, support groups, and treatment.

Following that initial encounter, I can’t remember when the issue of chest discomfort arose—the patient never complained to his family of chest pain. Like much of what happens in medicine, its discovery was a matter of routine diligence or dumb luck. At today’s visit, he had been free of discomfort over the last few days. He didn’t ascribe much significance to his vague symptoms.

His EKG, though, was not vague. I was surprised: “Good thing we checked.” We discussed options and settled on an urgent cardiology evaluation and a raft of medications. Death forestalled, the patient went into the restroom. When he hadn’t emerged in 5 minutes and wouldn’t respond to a knock, the door was unlocked and his body found on the floor.

“We are doing everything possible, but it doesn’t look good.” These words always sound hollow and insufficient when death calls unexpectedly. As the rescue squad rushed away, I gave directions to the daughter, knowing the small likelihood of a positive outcome. The expected news from the hospital came even before the frantic call from the family—they were lost, needed more directions. Better they receive bad news in person.

I spoke to the daughter the next day, and said how sorry I was—if only we had checked on him more quickly, summoned the ambulance sooner…. But the daughter was appreciative, guilty that she hadn’t divined her father’s problem sooner. I reassured her, provided my absolution, a liturgy of forgiveness.

She stopped in the office again the other day. She offered me a hug. “You lost your father too, recently?” Yes, but we had time to prepare. “It must be hard.”

Yes, death shouldn’t have the temerity to invade our office, our sanctuary. We talked about her mother, the reunion of family, the funeral. Death humbles us all; it is sad and sobering that the thread of life so thin. It is not only in the cure that good work is done, but during that bridge from life to death, and in ministering to those left living.

An overhead page interrupted my reverie; a usually placid nurse came running over: “Doctor, we have a problem.” Resuscitation was already started. The patient was blue and had no pulse. I began chest compressions as my colleague started to bag the patient and ACLS was initiated. A senior resident took over the chest compressions and I went over to talk to the family.

I silently reviewed what I knew about the family and patient, a mechanic who had begun to forget familiar things, like the alarm code at the car lot. He had come reluctantly to our office—his wife and daughter were concerned about Alzheimer’s disease. A picture of gradual memory impairment and increasing behavioral changes emerged. We discussed the prognosis, behavioral approaches, support groups, and treatment.

Following that initial encounter, I can’t remember when the issue of chest discomfort arose—the patient never complained to his family of chest pain. Like much of what happens in medicine, its discovery was a matter of routine diligence or dumb luck. At today’s visit, he had been free of discomfort over the last few days. He didn’t ascribe much significance to his vague symptoms.

His EKG, though, was not vague. I was surprised: “Good thing we checked.” We discussed options and settled on an urgent cardiology evaluation and a raft of medications. Death forestalled, the patient went into the restroom. When he hadn’t emerged in 5 minutes and wouldn’t respond to a knock, the door was unlocked and his body found on the floor.

“We are doing everything possible, but it doesn’t look good.” These words always sound hollow and insufficient when death calls unexpectedly. As the rescue squad rushed away, I gave directions to the daughter, knowing the small likelihood of a positive outcome. The expected news from the hospital came even before the frantic call from the family—they were lost, needed more directions. Better they receive bad news in person.

I spoke to the daughter the next day, and said how sorry I was—if only we had checked on him more quickly, summoned the ambulance sooner…. But the daughter was appreciative, guilty that she hadn’t divined her father’s problem sooner. I reassured her, provided my absolution, a liturgy of forgiveness.

She stopped in the office again the other day. She offered me a hug. “You lost your father too, recently?” Yes, but we had time to prepare. “It must be hard.”

Yes, death shouldn’t have the temerity to invade our office, our sanctuary. We talked about her mother, the reunion of family, the funeral. Death humbles us all; it is sad and sobering that the thread of life so thin. It is not only in the cure that good work is done, but during that bridge from life to death, and in ministering to those left living.

It’s the year 2010 and Harry and Louise are contemplating their choice of consumer-driven (directed) health care.

Before them at the kitchen table are piles of glossy brochures from the established health care giants extolling the virtues of their consumer-driven health care (CDHC) plans. “You are in control”; “We offer health care your way”; “We’re on your side.”

• “This one has such a nice cover, Harry.”
• “Yes, Louise, but the deductible for Viagra is higher, and look at the color scheme of their waiting rooms.”
• “Well, Harry, here is one that advertises a latte with each urgent care visit.”
• “Dear, it just is so complicated, how are we are ever going to make a decision?”

Welcome to the brave new world of consumer-driven (directed) health care.

The propaganda goes something like this: we provide you with a competitive choice of plans from which you rationally choose how to spend your health care dollar.

Closer to the truth is the bait and switch of dramatically limiting employers’ responsibility for health care provision and shifting costs to consumers.

The end result is Harry and Louise purchasing higher-deductible plans, reducing utilization of services (making choices based on short-term savings, not a rational consideration of longer-term value), and falling prey to marketing gimmicks rather than important attributes of quality.

Of course, big business and insurers love this development. In the name of consumer choice, employers emerge from the burden of skyrocketing health care expenses and the burden of plan negotiation. The wealthy supplement their care through health care savings vehicles. And the poor fall further behind.

Only by guaranteeing a basic health care and catastrophic package for all—and developing true measures of quality and value—can CDHC become a dream and not a nightmare.

“Harry, I’m too confused; let’s just watch TV.”

It’s the year 2010 and Harry and Louise are contemplating their choice of consumer-driven (directed) health care.

Before them at the kitchen table are piles of glossy brochures from the established health care giants extolling the virtues of their consumer-driven health care (CDHC) plans. “You are in control”; “We offer health care your way”; “We’re on your side.”

• “This one has such a nice cover, Harry.”
• “Yes, Louise, but the deductible for Viagra is higher, and look at the color scheme of their waiting rooms.”
• “Well, Harry, here is one that advertises a latte with each urgent care visit.”
• “Dear, it just is so complicated, how are we are ever going to make a decision?”

Welcome to the brave new world of consumer-driven (directed) health care.

The propaganda goes something like this: we provide you with a competitive choice of plans from which you rationally choose how to spend your health care dollar.

Closer to the truth is the bait and switch of dramatically limiting employers’ responsibility for health care provision and shifting costs to consumers.

The end result is Harry and Louise purchasing higher-deductible plans, reducing utilization of services (making choices based on short-term savings, not a rational consideration of longer-term value), and falling prey to marketing gimmicks rather than important attributes of quality.

Of course, big business and insurers love this development. In the name of consumer choice, employers emerge from the burden of skyrocketing health care expenses and the burden of plan negotiation. The wealthy supplement their care through health care savings vehicles. And the poor fall further behind.

Only by guaranteeing a basic health care and catastrophic package for all—and developing true measures of quality and value—can CDHC become a dream and not a nightmare.

“Harry, I’m too confused; let’s just watch TV.”

It’s the year 2010 and Harry and Louise are contemplating their choice of consumer-driven (directed) health care.

Before them at the kitchen table are piles of glossy brochures from the established health care giants extolling the virtues of their consumer-driven health care (CDHC) plans. “You are in control”; “We offer health care your way”; “We’re on your side.”

• “This one has such a nice cover, Harry.”
• “Yes, Louise, but the deductible for Viagra is higher, and look at the color scheme of their waiting rooms.”
• “Well, Harry, here is one that advertises a latte with each urgent care visit.”
• “Dear, it just is so complicated, how are we are ever going to make a decision?”

Welcome to the brave new world of consumer-driven (directed) health care.

The propaganda goes something like this: we provide you with a competitive choice of plans from which you rationally choose how to spend your health care dollar.

Closer to the truth is the bait and switch of dramatically limiting employers’ responsibility for health care provision and shifting costs to consumers.

The end result is Harry and Louise purchasing higher-deductible plans, reducing utilization of services (making choices based on short-term savings, not a rational consideration of longer-term value), and falling prey to marketing gimmicks rather than important attributes of quality.

Of course, big business and insurers love this development. In the name of consumer choice, employers emerge from the burden of skyrocketing health care expenses and the burden of plan negotiation. The wealthy supplement their care through health care savings vehicles. And the poor fall further behind.

Only by guaranteeing a basic health care and catastrophic package for all—and developing true measures of quality and value—can CDHC become a dream and not a nightmare.

“Harry, I’m too confused; let’s just watch TV.”

My father lies in the CCU. The steady rhythm of the dialysis machine and the occasional chirp of an alarm are all that suggest the location deep within a large University Hospital. A personal encounter with the health care system makes you aware of its achievements—and lacunae. While these observations may be personal and idiosyncratic, I hope you will consider their application to your own institution.

The warmth and dedication of my father’s health professionals show they clearly care: freely providing home phone and cell numbers, braving a major Nor’easter to get to work, explaining the medical circumstances in patient detail. The staff, from housekeeping to clerical, have gone out of their way to be supportive and understanding. They arrange transportation and laundry; remain calm amidst dire circumstance and frayed nerves; and do the best to maintain personalized attention. Clearly, our health care system does not suffer because of the quality of our people.

Our technology and therapeutics are amazing too—the intricacies of management of advanced heart and renal failure, the dazzling information afforded by PET scans, the marvels of artificial kidneys and ventricular assist devices. What was unimaginable even 5 years ago becomes routine. We should all be proud of such innovation and creativity.

But you don’t have to scratch the surface of this story too deeply to uncover substantial failings.

We communicate ineffectively interprofessionally. Basic patient information is neither portable nor readily accessible. Each transfer and consultation entails another elaborate information session. Vital bits of information are missing or inaccessible. Though clinicians try to communicate with one another, it’s akin to the game, “Operator,” wherein a message passed around a circle becomes garbled. In an age where hotels can track our preference for pillows, health care information system is an oxymoron.

Coordinating care, particularly in our special care units, remains a challenge. Intensivists are great at treating life-threatening chaos, but don’t seem to be very good or interested in coordinating more routine care. The lack of continuity and effective leadership (that’s the EP team’s issue, the hematology team’s call, the renal failure fellow’s job) leads to lack of clear goals, redundancy, and occasionally errors. Moreover, no one is very good talking about, let alone coordinating, end of life care. We are much better at lysing clots than planning palliative care.

Finally, provision for families is rudimentary. A hotel of sorts is attached to this University Hospital, but there is no place to eat, have one’s clothes cleaned, or buy a few essentials. Waiting rooms are cramped, and patient rooms small. Especially at our large academic hospitals, where patients come from all over the country, you might expect we could better consider the needs of families.

The saga of my father continues, and while my family and I know that his problems are largely irreversible, the prognosis grave, and death near—I trust we have the wisdom to help an ailing health system recover.

My father lies in the CCU. The steady rhythm of the dialysis machine and the occasional chirp of an alarm are all that suggest the location deep within a large University Hospital. A personal encounter with the health care system makes you aware of its achievements—and lacunae. While these observations may be personal and idiosyncratic, I hope you will consider their application to your own institution.

The warmth and dedication of my father’s health professionals show they clearly care: freely providing home phone and cell numbers, braving a major Nor’easter to get to work, explaining the medical circumstances in patient detail. The staff, from housekeeping to clerical, have gone out of their way to be supportive and understanding. They arrange transportation and laundry; remain calm amidst dire circumstance and frayed nerves; and do the best to maintain personalized attention. Clearly, our health care system does not suffer because of the quality of our people.

Our technology and therapeutics are amazing too—the intricacies of management of advanced heart and renal failure, the dazzling information afforded by PET scans, the marvels of artificial kidneys and ventricular assist devices. What was unimaginable even 5 years ago becomes routine. We should all be proud of such innovation and creativity.

But you don’t have to scratch the surface of this story too deeply to uncover substantial failings.

We communicate ineffectively interprofessionally. Basic patient information is neither portable nor readily accessible. Each transfer and consultation entails another elaborate information session. Vital bits of information are missing or inaccessible. Though clinicians try to communicate with one another, it’s akin to the game, “Operator,” wherein a message passed around a circle becomes garbled. In an age where hotels can track our preference for pillows, health care information system is an oxymoron.

Coordinating care, particularly in our special care units, remains a challenge. Intensivists are great at treating life-threatening chaos, but don’t seem to be very good or interested in coordinating more routine care. The lack of continuity and effective leadership (that’s the EP team’s issue, the hematology team’s call, the renal failure fellow’s job) leads to lack of clear goals, redundancy, and occasionally errors. Moreover, no one is very good talking about, let alone coordinating, end of life care. We are much better at lysing clots than planning palliative care.

Finally, provision for families is rudimentary. A hotel of sorts is attached to this University Hospital, but there is no place to eat, have one’s clothes cleaned, or buy a few essentials. Waiting rooms are cramped, and patient rooms small. Especially at our large academic hospitals, where patients come from all over the country, you might expect we could better consider the needs of families.

The saga of my father continues, and while my family and I know that his problems are largely irreversible, the prognosis grave, and death near—I trust we have the wisdom to help an ailing health system recover.

My father lies in the CCU. The steady rhythm of the dialysis machine and the occasional chirp of an alarm are all that suggest the location deep within a large University Hospital. A personal encounter with the health care system makes you aware of its achievements—and lacunae. While these observations may be personal and idiosyncratic, I hope you will consider their application to your own institution.

The warmth and dedication of my father’s health professionals show they clearly care: freely providing home phone and cell numbers, braving a major Nor’easter to get to work, explaining the medical circumstances in patient detail. The staff, from housekeeping to clerical, have gone out of their way to be supportive and understanding. They arrange transportation and laundry; remain calm amidst dire circumstance and frayed nerves; and do the best to maintain personalized attention. Clearly, our health care system does not suffer because of the quality of our people.

Our technology and therapeutics are amazing too—the intricacies of management of advanced heart and renal failure, the dazzling information afforded by PET scans, the marvels of artificial kidneys and ventricular assist devices. What was unimaginable even 5 years ago becomes routine. We should all be proud of such innovation and creativity.

But you don’t have to scratch the surface of this story too deeply to uncover substantial failings.

We communicate ineffectively interprofessionally. Basic patient information is neither portable nor readily accessible. Each transfer and consultation entails another elaborate information session. Vital bits of information are missing or inaccessible. Though clinicians try to communicate with one another, it’s akin to the game, “Operator,” wherein a message passed around a circle becomes garbled. In an age where hotels can track our preference for pillows, health care information system is an oxymoron.

Coordinating care, particularly in our special care units, remains a challenge. Intensivists are great at treating life-threatening chaos, but don’t seem to be very good or interested in coordinating more routine care. The lack of continuity and effective leadership (that’s the EP team’s issue, the hematology team’s call, the renal failure fellow’s job) leads to lack of clear goals, redundancy, and occasionally errors. Moreover, no one is very good talking about, let alone coordinating, end of life care. We are much better at lysing clots than planning palliative care.

Finally, provision for families is rudimentary. A hotel of sorts is attached to this University Hospital, but there is no place to eat, have one’s clothes cleaned, or buy a few essentials. Waiting rooms are cramped, and patient rooms small. Especially at our large academic hospitals, where patients come from all over the country, you might expect we could better consider the needs of families.

The saga of my father continues, and while my family and I know that his problems are largely irreversible, the prognosis grave, and death near—I trust we have the wisdom to help an ailing health system recover.

Dr Susman is in Antarctica this month, but do not despair: the Management found this mysterious missive stuffed between two ancient issues of JFP. We take no responsibility for its content.

• Those Honky-Tonk Insurance Company Blues
  I got those Honky-Tonk Insurance Company Blues.
  From North to South, from East to West,
  Preventin’ us from doing our best
  They manage my care, while they trim and pare.
  Downcoded my bills, changed my pills,
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues
  Whoever I see, they’re watchin’ me,
  Order a test? They say, “surely you jest.”
  You gotta toe the line, before you image that spine.
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues.
  They carved out depression, surely we’re regressing.
  Hassle my staff, it ain’t no laugh.
  Pay for performance, sure no romance.
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues.
  Managed my ‘Caid, rained on my parade.
  Slashed my fees, brought me to my knees.
  Now they blended my codes—we’re at the crossroads.
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I tell ya, got those down-and-out, Honky-Tonk Insurance Company Blues!
  They audit my charts, redirect my hearts.
  I’m losing my mind, they ain’t very kind.
  In the end it’s a shame, but who is to blame?
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues.
  I say, I got those Down-and-Out, Out-of-Control,
  Honky Tonky Insurance Company Blues.

Dr Susman is in Antarctica this month, but do not despair: the Management found this mysterious missive stuffed between two ancient issues of JFP. We take no responsibility for its content.

• Those Honky-Tonk Insurance Company Blues
  I got those Honky-Tonk Insurance Company Blues.
  From North to South, from East to West,
  Preventin’ us from doing our best
  They manage my care, while they trim and pare.
  Downcoded my bills, changed my pills,
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues
  Whoever I see, they’re watchin’ me,
  Order a test? They say, “surely you jest.”
  You gotta toe the line, before you image that spine.
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues.
  They carved out depression, surely we’re regressing.
  Hassle my staff, it ain’t no laugh.
  Pay for performance, sure no romance.
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues.
  Managed my ‘Caid, rained on my parade.
  Slashed my fees, brought me to my knees.
  Now they blended my codes—we’re at the crossroads.
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I tell ya, got those down-and-out, Honky-Tonk Insurance Company Blues!
  They audit my charts, redirect my hearts.
  I’m losing my mind, they ain’t very kind.
  In the end it’s a shame, but who is to blame?
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues.
  I say, I got those Down-and-Out, Out-of-Control,
  Honky Tonky Insurance Company Blues.

Dr Susman is in Antarctica this month, but do not despair: the Management found this mysterious missive stuffed between two ancient issues of JFP. We take no responsibility for its content.

• Those Honky-Tonk Insurance Company Blues
  I got those Honky-Tonk Insurance Company Blues.
  From North to South, from East to West,
  Preventin’ us from doing our best
  They manage my care, while they trim and pare.
  Downcoded my bills, changed my pills,
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues
  Whoever I see, they’re watchin’ me,
  Order a test? They say, “surely you jest.”
  You gotta toe the line, before you image that spine.
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues.
  They carved out depression, surely we’re regressing.
  Hassle my staff, it ain’t no laugh.
  Pay for performance, sure no romance.
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues.
  Managed my ‘Caid, rained on my parade.
  Slashed my fees, brought me to my knees.
  Now they blended my codes—we’re at the crossroads.
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I tell ya, got those down-and-out, Honky-Tonk Insurance Company Blues!
  They audit my charts, redirect my hearts.
  I’m losing my mind, they ain’t very kind.
  In the end it’s a shame, but who is to blame?
  I got those Honky-Tonk Insurance Company Blues.
  
  
• I got those Honky-Tonk Insurance Company Blues.
  I say, I got those Down-and-Out, Out-of-Control,
  Honky Tonky Insurance Company Blues.

The world changed when Bob Dole shared his tale of erectile dysfunction over prime time television. Now, not only is ED known to millions, but whenever you mention “getting into the game,” everyone snickers. From little purple pills to ads suggesting that your shyness might be curable, direct-to-consumer advertising has become a huge part of pharmaceutical marketing. For the most part, in my mind, such efforts have had a positive effect—and not just on drug manufacturers’ bottom lines.

Discussing potentially stigmatizing issues such as impotence (oops, I meant ED) or depression have become much more socially acceptable. With politicians and celebrities openly discussing their most intimate problems, many more patients come to my office requesting help. And such dialogue has certainly raised awareness about important medical problems that have been relegated to embarrassed locker room conversations.

Of course, there are problems. We have all had patients self-diagnose incorrectly, demand unwarranted treatments, or request an expensive medication when an inexpensive, equally effective alternative exists. And for a condition to garner any attention, a patented product must be available to promote. For years I have lectured on sleep disorders, promoting the use of dopaminergic agents such as levodopa/carbidopa for restless legs syndrome. But only recently, with the approval of a new generation of expensive medications, have pharmaceutical firms begun educating the public.

In fact, I often wonder if conditions are made up to promote products. Take social anxiety disorder (SAD). Sure, there are people who can benefit from treatment, but I wonder if the vast majority of such patients are simply shy, reserved, or reticent. Now we have screening tools for SAD, patient education materials, and a raft of ads directed to promoting diagnosis and treatment. The downside of treatment and the potentially stigmatizing effect of labeling a trait as a problem are seldom considered. Likewise, fatigue is a treatable condition requiring expensive new medication; everyone with a bit of heartburn rushes for a pill. I really wish companies would refrain from touting a specific pill or treatment, and confine their message to, “If you think you have this problem, ask your doctor. Effective treatment is available.”

Nonetheless, I wouldn’t trade today’s situation with the “good ole days.” I am happy that patients actually can talk about sexual dysfunction or depression, and know they are in the company of the stars.

The world changed when Bob Dole shared his tale of erectile dysfunction over prime time television. Now, not only is ED known to millions, but whenever you mention “getting into the game,” everyone snickers. From little purple pills to ads suggesting that your shyness might be curable, direct-to-consumer advertising has become a huge part of pharmaceutical marketing. For the most part, in my mind, such efforts have had a positive effect—and not just on drug manufacturers’ bottom lines.

Discussing potentially stigmatizing issues such as impotence (oops, I meant ED) or depression have become much more socially acceptable. With politicians and celebrities openly discussing their most intimate problems, many more patients come to my office requesting help. And such dialogue has certainly raised awareness about important medical problems that have been relegated to embarrassed locker room conversations.

Of course, there are problems. We have all had patients self-diagnose incorrectly, demand unwarranted treatments, or request an expensive medication when an inexpensive, equally effective alternative exists. And for a condition to garner any attention, a patented product must be available to promote. For years I have lectured on sleep disorders, promoting the use of dopaminergic agents such as levodopa/carbidopa for restless legs syndrome. But only recently, with the approval of a new generation of expensive medications, have pharmaceutical firms begun educating the public.

In fact, I often wonder if conditions are made up to promote products. Take social anxiety disorder (SAD). Sure, there are people who can benefit from treatment, but I wonder if the vast majority of such patients are simply shy, reserved, or reticent. Now we have screening tools for SAD, patient education materials, and a raft of ads directed to promoting diagnosis and treatment. The downside of treatment and the potentially stigmatizing effect of labeling a trait as a problem are seldom considered. Likewise, fatigue is a treatable condition requiring expensive new medication; everyone with a bit of heartburn rushes for a pill. I really wish companies would refrain from touting a specific pill or treatment, and confine their message to, “If you think you have this problem, ask your doctor. Effective treatment is available.”

Nonetheless, I wouldn’t trade today’s situation with the “good ole days.” I am happy that patients actually can talk about sexual dysfunction or depression, and know they are in the company of the stars.

The world changed when Bob Dole shared his tale of erectile dysfunction over prime time television. Now, not only is ED known to millions, but whenever you mention “getting into the game,” everyone snickers. From little purple pills to ads suggesting that your shyness might be curable, direct-to-consumer advertising has become a huge part of pharmaceutical marketing. For the most part, in my mind, such efforts have had a positive effect—and not just on drug manufacturers’ bottom lines.

Discussing potentially stigmatizing issues such as impotence (oops, I meant ED) or depression have become much more socially acceptable. With politicians and celebrities openly discussing their most intimate problems, many more patients come to my office requesting help. And such dialogue has certainly raised awareness about important medical problems that have been relegated to embarrassed locker room conversations.

Of course, there are problems. We have all had patients self-diagnose incorrectly, demand unwarranted treatments, or request an expensive medication when an inexpensive, equally effective alternative exists. And for a condition to garner any attention, a patented product must be available to promote. For years I have lectured on sleep disorders, promoting the use of dopaminergic agents such as levodopa/carbidopa for restless legs syndrome. But only recently, with the approval of a new generation of expensive medications, have pharmaceutical firms begun educating the public.

In fact, I often wonder if conditions are made up to promote products. Take social anxiety disorder (SAD). Sure, there are people who can benefit from treatment, but I wonder if the vast majority of such patients are simply shy, reserved, or reticent. Now we have screening tools for SAD, patient education materials, and a raft of ads directed to promoting diagnosis and treatment. The downside of treatment and the potentially stigmatizing effect of labeling a trait as a problem are seldom considered. Likewise, fatigue is a treatable condition requiring expensive new medication; everyone with a bit of heartburn rushes for a pill. I really wish companies would refrain from touting a specific pill or treatment, and confine their message to, “If you think you have this problem, ask your doctor. Effective treatment is available.”

Nonetheless, I wouldn’t trade today’s situation with the “good ole days.” I am happy that patients actually can talk about sexual dysfunction or depression, and know they are in the company of the stars.

The office was slow yesterday, I was tired of doing well-child visits, so I closed at 2:00. While driving home, I stopped at Starbucks and ordered a latte. The bedraggled counter person said coffee was not being served today, but how about a tomato juice?

The passenger count on my Delta flight was so light my plane was canceled and used on a flight to Charleston.

If you are wondering what these scenarios have to do with you and your office, take this simple test:

POP QUIZ: Which of the following are true of your practice?

• I am open over the lunch hour to accommodate the increasing number of harried working adults
• My patients spend less than 15 minutes waiting in my office (total wait time—include waiting room time, time waiting in your exam room, and time waiting for testing)
• Patients can call in the same day for their appointments
• Information is gathered once in your office and available immediately to all of your staff
• You use the Internet to allow patients to make their appointments and receive their routine lab results
• I have a complete database on all my patients which is updated at every visit
• I offer integrated laboratory and ancillary services—I am a one-stop shop for all my patient’s health care needs, from mental health to holter monitoring
• Every phone call is answered by a real live person within 3 rings (subtract 3 points if your face to the world is an automated answering machine)
• Every established patient is addressed by their preferred name
• New patients are personally oriented to your practice.

Add up the “yes” responses and score as follows:

• 1–3 (enroll in an Institute for Healthcare Improvement Course)
• 4–6 (order a book on lean thinking, advanced access scheduling or group visits)
• 7–8 (you have already been to an IHI course and are serious about your patient’s satisfaction)
• 9 (you teach an IHI course)
• 10 (e-mail me and share your story!)

In the meantime, I’ll be waiting for the next flight to Cincinnati…

The office was slow yesterday, I was tired of doing well-child visits, so I closed at 2:00. While driving home, I stopped at Starbucks and ordered a latte. The bedraggled counter person said coffee was not being served today, but how about a tomato juice?

The passenger count on my Delta flight was so light my plane was canceled and used on a flight to Charleston.

If you are wondering what these scenarios have to do with you and your office, take this simple test:

POP QUIZ: Which of the following are true of your practice?

• I am open over the lunch hour to accommodate the increasing number of harried working adults
• My patients spend less than 15 minutes waiting in my office (total wait time—include waiting room time, time waiting in your exam room, and time waiting for testing)
• Patients can call in the same day for their appointments
• Information is gathered once in your office and available immediately to all of your staff
• You use the Internet to allow patients to make their appointments and receive their routine lab results
• I have a complete database on all my patients which is updated at every visit
• I offer integrated laboratory and ancillary services—I am a one-stop shop for all my patient’s health care needs, from mental health to holter monitoring
• Every phone call is answered by a real live person within 3 rings (subtract 3 points if your face to the world is an automated answering machine)
• Every established patient is addressed by their preferred name
• New patients are personally oriented to your practice.

Add up the “yes” responses and score as follows:

• 1–3 (enroll in an Institute for Healthcare Improvement Course)
• 4–6 (order a book on lean thinking, advanced access scheduling or group visits)
• 7–8 (you have already been to an IHI course and are serious about your patient’s satisfaction)
• 9 (you teach an IHI course)
• 10 (e-mail me and share your story!)

In the meantime, I’ll be waiting for the next flight to Cincinnati…

The office was slow yesterday, I was tired of doing well-child visits, so I closed at 2:00. While driving home, I stopped at Starbucks and ordered a latte. The bedraggled counter person said coffee was not being served today, but how about a tomato juice?

The passenger count on my Delta flight was so light my plane was canceled and used on a flight to Charleston.

If you are wondering what these scenarios have to do with you and your office, take this simple test:

POP QUIZ: Which of the following are true of your practice?

• I am open over the lunch hour to accommodate the increasing number of harried working adults
• My patients spend less than 15 minutes waiting in my office (total wait time—include waiting room time, time waiting in your exam room, and time waiting for testing)
• Patients can call in the same day for their appointments
• Information is gathered once in your office and available immediately to all of your staff
• You use the Internet to allow patients to make their appointments and receive their routine lab results
• I have a complete database on all my patients which is updated at every visit
• I offer integrated laboratory and ancillary services—I am a one-stop shop for all my patient’s health care needs, from mental health to holter monitoring
• Every phone call is answered by a real live person within 3 rings (subtract 3 points if your face to the world is an automated answering machine)
• Every established patient is addressed by their preferred name
• New patients are personally oriented to your practice.

Add up the “yes” responses and score as follows:

• 1–3 (enroll in an Institute for Healthcare Improvement Course)
• 4–6 (order a book on lean thinking, advanced access scheduling or group visits)
• 7–8 (you have already been to an IHI course and are serious about your patient’s satisfaction)
• 9 (you teach an IHI course)
• 10 (e-mail me and share your story!)

In the meantime, I’ll be waiting for the next flight to Cincinnati…