Commentary

The other day, I had to look up “whispered pectoriloquy” to be reminded of what it meant. The last time I had seen the term was when I was a third-year medical student.

I was motivated to look it up now as I was reading the review of systems in a patient note generated from an electronic health record. Interestingly, the note was written by a consulting urologist.

I have become accustomed to only glancing at the review of systems in most of the medical letters I receive, but this particular review of systems caught my attention. As I looked carefully at it, I noticed that the urologist documented that the patient denied chest pain, shortness of breath, double vision, and – oddly – loose stools. In fairness, the note also documented that the patient denied blood in his urine and nocturia.

I was quite doubtful that the physician actually asked the patient about chest pain and double vision, so I was facing a dilemma: believe all of the note, none of the note, or just the parts I felt confident were actually asked.

For a long time, I really did not think much about the problem. I just processed the observation with a sense of mild amusement and absurdity, and mostly with an acceptance that these kinds of observations were an annoying but unavoidable side effect of systems created by computer engineers and forced upon doctors.

But I became more concerned as I read further. The physical exam documented a detailed cardiac exam with no murmurs, rubs, or gallops, and the pulmonary exam showed no wheezing or whispered pectoriloquy. These documentation inaccuracies, while amusing, truly are a source of potential liability and ultimately detract from our ability to find the important information contained within a note.

Fundamentally, medical notes are written to document what occurred during a patient visit. They should allow the physician to recall what happened at the visit, whether the patient follows up in a day, a week, or 3 years later. They also need to communicate the details of the visit to any other clinician who may see the patient at some point in the future.

In recent decades, notes also have become the sole evidence required to justify physician charges. To bill at a certain rate, a physician must document a minimum amount of information, including a specific number of elements in the review of systems and the physical exam. Recognizing that compliance with billing requirements is an important goal of clinicians, many EHRs have made it too easy to “bloat” a note by including reams of irrelevant information – thereby making it difficult to find the important information the note was intended to communicate in the first place.

Notes from some EHRs remind us of the Wendy’s commercial from the 1980s: They force us to ask, “Where’s the beef?”

This is because many EHR implementations rely on default settings. These maximize documentation for billing but unfortunately leave the “beef” (in our case, the real information relevant to patient care) buried in lines of irrelevant, specious, and sometimes downright fictitious information.

We can do better. Virtually every EHR currently in use allows clinicians to customize fields so that notes can be easily written to reflect the realities of our differing practices.

Put more simply, you really can (and should) have a review of systems that is relevant to what you do.

If you always ask about chest pain, difficulty breathing, and abdominal pain, you can include negative responses to those questions with one click and then add in any positive aspects the patient may report. If you are seeing a patient with asthma and you generally ask the same questions – exacerbations in the last month, frequency of the use of albuterol, nighttime awakenings, symptoms with exercise, etc. – most EHR systems will allow you to set up the record to populate an asthma review of systems that includes defined responses you can individualize for each patient.

Electronic documentation of the physical exam also should reflect the examination that you routinely do by default. Then you can make simple changes to adapt your personalized predefined settings and correctly reflect what occurred with each patient.

For that same asthma patient, the physical exam should give the details of the heart and lung exam but should not include any mention of an abdominal exam unless one was actually done. A current high-quality EHR also should populate the appropriate physical exam areas with one click of a button.

It has been more than 3 years since the majority of practices transitioned to electronic health records, but we still see far too many clinicians struggling with systems and describing data that reflect things they have not done, all due to the use of default settings that have never been changed. It is important to understand how to customize your EHR to meet your needs and to make the individual efforts required to learn how to effectively use the current instruments of our craft.

As for whispered pectoriloquy, it is the increased loudness of a whispered word heard on auscultation over an area of lung consolidation. It is similar to tactile fremitus, where consolidation is noted by the vibratory feel in your hand placed on the chest of a patient. It should be a very rare event in our day and age that any description of whispered pectoriloquy should sneak its way into our record, particularly for a urology visit.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The other day, I had to look up “whispered pectoriloquy” to be reminded of what it meant. The last time I had seen the term was when I was a third-year medical student.

I was motivated to look it up now as I was reading the review of systems in a patient note generated from an electronic health record. Interestingly, the note was written by a consulting urologist.

I have become accustomed to only glancing at the review of systems in most of the medical letters I receive, but this particular review of systems caught my attention. As I looked carefully at it, I noticed that the urologist documented that the patient denied chest pain, shortness of breath, double vision, and – oddly – loose stools. In fairness, the note also documented that the patient denied blood in his urine and nocturia.

I was quite doubtful that the physician actually asked the patient about chest pain and double vision, so I was facing a dilemma: believe all of the note, none of the note, or just the parts I felt confident were actually asked.

For a long time, I really did not think much about the problem. I just processed the observation with a sense of mild amusement and absurdity, and mostly with an acceptance that these kinds of observations were an annoying but unavoidable side effect of systems created by computer engineers and forced upon doctors.

But I became more concerned as I read further. The physical exam documented a detailed cardiac exam with no murmurs, rubs, or gallops, and the pulmonary exam showed no wheezing or whispered pectoriloquy. These documentation inaccuracies, while amusing, truly are a source of potential liability and ultimately detract from our ability to find the important information contained within a note.

Fundamentally, medical notes are written to document what occurred during a patient visit. They should allow the physician to recall what happened at the visit, whether the patient follows up in a day, a week, or 3 years later. They also need to communicate the details of the visit to any other clinician who may see the patient at some point in the future.

In recent decades, notes also have become the sole evidence required to justify physician charges. To bill at a certain rate, a physician must document a minimum amount of information, including a specific number of elements in the review of systems and the physical exam. Recognizing that compliance with billing requirements is an important goal of clinicians, many EHRs have made it too easy to “bloat” a note by including reams of irrelevant information – thereby making it difficult to find the important information the note was intended to communicate in the first place.

Notes from some EHRs remind us of the Wendy’s commercial from the 1980s: They force us to ask, “Where’s the beef?”

This is because many EHR implementations rely on default settings. These maximize documentation for billing but unfortunately leave the “beef” (in our case, the real information relevant to patient care) buried in lines of irrelevant, specious, and sometimes downright fictitious information.

We can do better. Virtually every EHR currently in use allows clinicians to customize fields so that notes can be easily written to reflect the realities of our differing practices.

Put more simply, you really can (and should) have a review of systems that is relevant to what you do.

If you always ask about chest pain, difficulty breathing, and abdominal pain, you can include negative responses to those questions with one click and then add in any positive aspects the patient may report. If you are seeing a patient with asthma and you generally ask the same questions – exacerbations in the last month, frequency of the use of albuterol, nighttime awakenings, symptoms with exercise, etc. – most EHR systems will allow you to set up the record to populate an asthma review of systems that includes defined responses you can individualize for each patient.

Electronic documentation of the physical exam also should reflect the examination that you routinely do by default. Then you can make simple changes to adapt your personalized predefined settings and correctly reflect what occurred with each patient.

For that same asthma patient, the physical exam should give the details of the heart and lung exam but should not include any mention of an abdominal exam unless one was actually done. A current high-quality EHR also should populate the appropriate physical exam areas with one click of a button.

It has been more than 3 years since the majority of practices transitioned to electronic health records, but we still see far too many clinicians struggling with systems and describing data that reflect things they have not done, all due to the use of default settings that have never been changed. It is important to understand how to customize your EHR to meet your needs and to make the individual efforts required to learn how to effectively use the current instruments of our craft.

As for whispered pectoriloquy, it is the increased loudness of a whispered word heard on auscultation over an area of lung consolidation. It is similar to tactile fremitus, where consolidation is noted by the vibratory feel in your hand placed on the chest of a patient. It should be a very rare event in our day and age that any description of whispered pectoriloquy should sneak its way into our record, particularly for a urology visit.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The other day, I had to look up “whispered pectoriloquy” to be reminded of what it meant. The last time I had seen the term was when I was a third-year medical student.

I was motivated to look it up now as I was reading the review of systems in a patient note generated from an electronic health record. Interestingly, the note was written by a consulting urologist.

I have become accustomed to only glancing at the review of systems in most of the medical letters I receive, but this particular review of systems caught my attention. As I looked carefully at it, I noticed that the urologist documented that the patient denied chest pain, shortness of breath, double vision, and – oddly – loose stools. In fairness, the note also documented that the patient denied blood in his urine and nocturia.

I was quite doubtful that the physician actually asked the patient about chest pain and double vision, so I was facing a dilemma: believe all of the note, none of the note, or just the parts I felt confident were actually asked.

For a long time, I really did not think much about the problem. I just processed the observation with a sense of mild amusement and absurdity, and mostly with an acceptance that these kinds of observations were an annoying but unavoidable side effect of systems created by computer engineers and forced upon doctors.

But I became more concerned as I read further. The physical exam documented a detailed cardiac exam with no murmurs, rubs, or gallops, and the pulmonary exam showed no wheezing or whispered pectoriloquy. These documentation inaccuracies, while amusing, truly are a source of potential liability and ultimately detract from our ability to find the important information contained within a note.

Fundamentally, medical notes are written to document what occurred during a patient visit. They should allow the physician to recall what happened at the visit, whether the patient follows up in a day, a week, or 3 years later. They also need to communicate the details of the visit to any other clinician who may see the patient at some point in the future.

In recent decades, notes also have become the sole evidence required to justify physician charges. To bill at a certain rate, a physician must document a minimum amount of information, including a specific number of elements in the review of systems and the physical exam. Recognizing that compliance with billing requirements is an important goal of clinicians, many EHRs have made it too easy to “bloat” a note by including reams of irrelevant information – thereby making it difficult to find the important information the note was intended to communicate in the first place.

Notes from some EHRs remind us of the Wendy’s commercial from the 1980s: They force us to ask, “Where’s the beef?”

This is because many EHR implementations rely on default settings. These maximize documentation for billing but unfortunately leave the “beef” (in our case, the real information relevant to patient care) buried in lines of irrelevant, specious, and sometimes downright fictitious information.

We can do better. Virtually every EHR currently in use allows clinicians to customize fields so that notes can be easily written to reflect the realities of our differing practices.

Put more simply, you really can (and should) have a review of systems that is relevant to what you do.

If you always ask about chest pain, difficulty breathing, and abdominal pain, you can include negative responses to those questions with one click and then add in any positive aspects the patient may report. If you are seeing a patient with asthma and you generally ask the same questions – exacerbations in the last month, frequency of the use of albuterol, nighttime awakenings, symptoms with exercise, etc. – most EHR systems will allow you to set up the record to populate an asthma review of systems that includes defined responses you can individualize for each patient.

Electronic documentation of the physical exam also should reflect the examination that you routinely do by default. Then you can make simple changes to adapt your personalized predefined settings and correctly reflect what occurred with each patient.

For that same asthma patient, the physical exam should give the details of the heart and lung exam but should not include any mention of an abdominal exam unless one was actually done. A current high-quality EHR also should populate the appropriate physical exam areas with one click of a button.

It has been more than 3 years since the majority of practices transitioned to electronic health records, but we still see far too many clinicians struggling with systems and describing data that reflect things they have not done, all due to the use of default settings that have never been changed. It is important to understand how to customize your EHR to meet your needs and to make the individual efforts required to learn how to effectively use the current instruments of our craft.

As for whispered pectoriloquy, it is the increased loudness of a whispered word heard on auscultation over an area of lung consolidation. It is similar to tactile fremitus, where consolidation is noted by the vibratory feel in your hand placed on the chest of a patient. It should be a very rare event in our day and age that any description of whispered pectoriloquy should sneak its way into our record, particularly for a urology visit.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

After 40 years as a PA (including 21 in academia), tucking myself safely into my seventh decade of life, I was feeling fairly invincible. Yes, I was experiencing increased fatigue and intermittent dizziness, but I attributed those to normal aging and my hectic schedule. Purely to get my colleagues and loved ones off my back, I agreed to see my primary care physician—but, feeling that I had little time for this and knowing that my health was just fine, thank you, I scheduled my appointment for a month later.

That appointment resulted in a referral to a cardiologist (which I didn’t think I needed) and a carotid ultrasound (which yielded negative results). I was still begrudging the time spent on these appointments, when my treadmill test revealed some ST changes in the lateral leads. OK, yes, I do have a positive family history for heart disease! But still, I was surprised.

This finding led to a nuclear treadmill test, which showed some ischemia. The cardiologist suggested an angiogram to rule out a probable false-positive result. Now, I really didn’t have time for this, either—but having gone this far, I felt it was important just to get it over with. Thank goodness I did!

During my angiogram (by the way, they give you great LaLa Land drugs), the interventional cardiologist discovered a 95% blockage of the circumflex, a 95% blockage of the right coronary artery, and a 60% blockage of the LAD. The big decision at that point, amidst the obvious shock of my mortality, was whether to opt for an open-heart bypass or stents. I chose stents (which, by the way, have had a significant impact on my energy level). My cardiologist tells me that, without the stents, if I had experienced a total occlusion event, I would not have survived. Quite a sobering thought!

My purpose in sharing this story is not to call attention to myself but rather to offer a wake-up call to those of us who think we are invincible. Many colleagues who have heard my story have decided to get their own long-delayed treadmill or other health-related tests. So here is my call to action to all of you: Take care of your health. The irony is that, for health care providers, this can be difficult.

Those who care for others often have a tough time caring for themselves. We know that physicians are notoriously bad patients, and I think PAs/NPs are no different. We deal with life-and-death issues all the time, and outward displays of distress are, at a minimum, discouraged. In general, our training and accumulated experience help us to develop good coping skills: We are taught to ignore basic human needs (like hunger and fatigue) and to remain capable, competent, and compassionate clinicians under highly stressful conditions.

Nonetheless, we experience these high levels of stress and seldom act to relieve them. As long ago as 1886, Dr William Ogle exposed clinicians’ vulnerability to high mortality risks, but to this day, the subject remains fairly neglected.¹ Perhaps as a result of stigma—we worry about confidentiality, or that our colleagues will consider us inadequate or incompetent clinicians, or that a display of “weakness” means we have failed in some way—we often wait too long to seek treatment. Often, it takes a crisis before we stop to care for ourselves.

Continue for suggestions on how to take care of yourself >>

We promote the health of our patients, but we often forget that if health is to be sustained, those who provide the help must be capable of caring for both themselves and others.² Without being overly prescriptive, I would like to share with you some suggestions for how you can take care of yourself:

1. Maintain a positive attitude. Yes, we often set ourselves up for failure, but we must have patience with ourselves. There are countless ways to practice reflection and find some time to think; it could entail an artistic outlet such as painting, sculpting, sewing, or singing. A colleague of mine listens to affirmations (now available by smartphone app) that she says help her succeed in her daily endeavors.

2. Identify your support systems. You know who they are: family, friends, and colleagues who bring positive support to your life. Spend more time with them. Clinicians with strong family or social connections are generally healthier than those who lack a support network. Make plans with supportive family members and friends, or seek out activities where you can meet new people.

3. Choose healthy, well-balanced meals. This is probably one of the most difficult tasks, due to our hectic and busy lifestyles. We should strive for low-fat, low-sugar, low-salt, high-fiber, and reasonably low-calorie meals. And drink more water—at least 6 to 8 glasses per day.

4. Get an appropriate amount of sleep. Restorative rest is one of the things you can control and should—no, must—give priority to. It is known that sleep is key to competent delivery of care. The National Sleep Foundation suggests seven to nine hours per night for those ages 26 to 64 and seven to eight hours per night for those older than 65.³ (In fact, some studies have suggested an increase in stroke linked to sleeping longer in older age.⁴)

5. Exercise. Schedule time for a sustainable exercise program. Put it on your calendar, and make that the one meeting that is essential. (This is another area in which technology can help, by providing reminders that you need to get up and move.) You don’t have to go to the gym twice a day or run a marathon. Walking for an hour three or four times a week will make a difference; even a 5-minute walk after a stressful meeting can help. Just do it!

6. Schedule time for R&R. Over the past decade, a staggering number of studies have demonstrated that our work performance plummets when we work prolonged periods without a break. Use your vacation time! A recent Harvard Business Review article reported that employees who take vacation are actually more productive.⁵ Make time for yourself—no one else will!

7. Take care of your mental health. Stress is a fact of life. Do what you can to relieve it; develop good coping skills and use them. You may find that keeping a journal in which you can vent your frustrations and fears or taking your dog for a long walk helps to relieve tension. Find what works for you. And make sure to laugh and find the humor in life. Laughter has been shown to boost the immune system and ease pain. It’s a great way to relax!

8. Take care of your physical health. Caring for your body is one of the best things you can do for yourself. Reduce or eliminate risk factors. Please get your routine health promotion procedures done (eg, colonoscopy, Pap smear, mammogram). And when you experience signs of illness, don’t ignore them! Seek advice early for anything out of the ordinary, be it intermittent dizziness, recurrent fatigue, unintended weight loss, feelings of despair—I could go on.

If even a handful of you heed these suggestions, and doing so makes a difference in your health and longevity, then I have completed my mission for this editorial. 

We should be role models for our patients. The societal focus on healthy lifestyles is a challenge for all of us, but the benefits are enormous. I would love to hear from you regarding ways to enhance our physical and mental health and avoid early morbidity or mortality. You can reach me at PAEditor@frontlinemedcom.com.

REFERENCES
1. Woods R. Physician, heal thyself: the health and mortality of Victorian doctors. Soc Hist Med. 1966;9(1):1-30.
2.  Borchardt GL. Role models for health promotion: the challenge for nurses. Nurs Forum. 2000;35(3):29-32.
3. Hershkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1(1):40-43.
4. Leng Y, Cappuccio FP, Wainwright NWJ, et al. Sleep duration and risk of fatal and nonfatal stroke: a prospective study and meta-analysis. Neurology. 2015;84(11):1072-1079.
5. Friedman R. Dear boss: your team wants you to go on vacation. Harvard Bus Rev. June 15, 2015.

After 40 years as a PA (including 21 in academia), tucking myself safely into my seventh decade of life, I was feeling fairly invincible. Yes, I was experiencing increased fatigue and intermittent dizziness, but I attributed those to normal aging and my hectic schedule. Purely to get my colleagues and loved ones off my back, I agreed to see my primary care physician—but, feeling that I had little time for this and knowing that my health was just fine, thank you, I scheduled my appointment for a month later.

That appointment resulted in a referral to a cardiologist (which I didn’t think I needed) and a carotid ultrasound (which yielded negative results). I was still begrudging the time spent on these appointments, when my treadmill test revealed some ST changes in the lateral leads. OK, yes, I do have a positive family history for heart disease! But still, I was surprised.

This finding led to a nuclear treadmill test, which showed some ischemia. The cardiologist suggested an angiogram to rule out a probable false-positive result. Now, I really didn’t have time for this, either—but having gone this far, I felt it was important just to get it over with. Thank goodness I did!

During my angiogram (by the way, they give you great LaLa Land drugs), the interventional cardiologist discovered a 95% blockage of the circumflex, a 95% blockage of the right coronary artery, and a 60% blockage of the LAD. The big decision at that point, amidst the obvious shock of my mortality, was whether to opt for an open-heart bypass or stents. I chose stents (which, by the way, have had a significant impact on my energy level). My cardiologist tells me that, without the stents, if I had experienced a total occlusion event, I would not have survived. Quite a sobering thought!

My purpose in sharing this story is not to call attention to myself but rather to offer a wake-up call to those of us who think we are invincible. Many colleagues who have heard my story have decided to get their own long-delayed treadmill or other health-related tests. So here is my call to action to all of you: Take care of your health. The irony is that, for health care providers, this can be difficult.

Those who care for others often have a tough time caring for themselves. We know that physicians are notoriously bad patients, and I think PAs/NPs are no different. We deal with life-and-death issues all the time, and outward displays of distress are, at a minimum, discouraged. In general, our training and accumulated experience help us to develop good coping skills: We are taught to ignore basic human needs (like hunger and fatigue) and to remain capable, competent, and compassionate clinicians under highly stressful conditions.

Nonetheless, we experience these high levels of stress and seldom act to relieve them. As long ago as 1886, Dr William Ogle exposed clinicians’ vulnerability to high mortality risks, but to this day, the subject remains fairly neglected.¹ Perhaps as a result of stigma—we worry about confidentiality, or that our colleagues will consider us inadequate or incompetent clinicians, or that a display of “weakness” means we have failed in some way—we often wait too long to seek treatment. Often, it takes a crisis before we stop to care for ourselves.

Continue for suggestions on how to take care of yourself >>

We promote the health of our patients, but we often forget that if health is to be sustained, those who provide the help must be capable of caring for both themselves and others.² Without being overly prescriptive, I would like to share with you some suggestions for how you can take care of yourself:

1. Maintain a positive attitude. Yes, we often set ourselves up for failure, but we must have patience with ourselves. There are countless ways to practice reflection and find some time to think; it could entail an artistic outlet such as painting, sculpting, sewing, or singing. A colleague of mine listens to affirmations (now available by smartphone app) that she says help her succeed in her daily endeavors.

2. Identify your support systems. You know who they are: family, friends, and colleagues who bring positive support to your life. Spend more time with them. Clinicians with strong family or social connections are generally healthier than those who lack a support network. Make plans with supportive family members and friends, or seek out activities where you can meet new people.

3. Choose healthy, well-balanced meals. This is probably one of the most difficult tasks, due to our hectic and busy lifestyles. We should strive for low-fat, low-sugar, low-salt, high-fiber, and reasonably low-calorie meals. And drink more water—at least 6 to 8 glasses per day.

4. Get an appropriate amount of sleep. Restorative rest is one of the things you can control and should—no, must—give priority to. It is known that sleep is key to competent delivery of care. The National Sleep Foundation suggests seven to nine hours per night for those ages 26 to 64 and seven to eight hours per night for those older than 65.³ (In fact, some studies have suggested an increase in stroke linked to sleeping longer in older age.⁴)

5. Exercise. Schedule time for a sustainable exercise program. Put it on your calendar, and make that the one meeting that is essential. (This is another area in which technology can help, by providing reminders that you need to get up and move.) You don’t have to go to the gym twice a day or run a marathon. Walking for an hour three or four times a week will make a difference; even a 5-minute walk after a stressful meeting can help. Just do it!

6. Schedule time for R&R. Over the past decade, a staggering number of studies have demonstrated that our work performance plummets when we work prolonged periods without a break. Use your vacation time! A recent Harvard Business Review article reported that employees who take vacation are actually more productive.⁵ Make time for yourself—no one else will!

7. Take care of your mental health. Stress is a fact of life. Do what you can to relieve it; develop good coping skills and use them. You may find that keeping a journal in which you can vent your frustrations and fears or taking your dog for a long walk helps to relieve tension. Find what works for you. And make sure to laugh and find the humor in life. Laughter has been shown to boost the immune system and ease pain. It’s a great way to relax!

8. Take care of your physical health. Caring for your body is one of the best things you can do for yourself. Reduce or eliminate risk factors. Please get your routine health promotion procedures done (eg, colonoscopy, Pap smear, mammogram). And when you experience signs of illness, don’t ignore them! Seek advice early for anything out of the ordinary, be it intermittent dizziness, recurrent fatigue, unintended weight loss, feelings of despair—I could go on.

If even a handful of you heed these suggestions, and doing so makes a difference in your health and longevity, then I have completed my mission for this editorial. 

We should be role models for our patients. The societal focus on healthy lifestyles is a challenge for all of us, but the benefits are enormous. I would love to hear from you regarding ways to enhance our physical and mental health and avoid early morbidity or mortality. You can reach me at PAEditor@frontlinemedcom.com.

REFERENCES
1. Woods R. Physician, heal thyself: the health and mortality of Victorian doctors. Soc Hist Med. 1966;9(1):1-30.
2.  Borchardt GL. Role models for health promotion: the challenge for nurses. Nurs Forum. 2000;35(3):29-32.
3. Hershkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1(1):40-43.
4. Leng Y, Cappuccio FP, Wainwright NWJ, et al. Sleep duration and risk of fatal and nonfatal stroke: a prospective study and meta-analysis. Neurology. 2015;84(11):1072-1079.
5. Friedman R. Dear boss: your team wants you to go on vacation. Harvard Bus Rev. June 15, 2015.

After 40 years as a PA (including 21 in academia), tucking myself safely into my seventh decade of life, I was feeling fairly invincible. Yes, I was experiencing increased fatigue and intermittent dizziness, but I attributed those to normal aging and my hectic schedule. Purely to get my colleagues and loved ones off my back, I agreed to see my primary care physician—but, feeling that I had little time for this and knowing that my health was just fine, thank you, I scheduled my appointment for a month later.

That appointment resulted in a referral to a cardiologist (which I didn’t think I needed) and a carotid ultrasound (which yielded negative results). I was still begrudging the time spent on these appointments, when my treadmill test revealed some ST changes in the lateral leads. OK, yes, I do have a positive family history for heart disease! But still, I was surprised.

This finding led to a nuclear treadmill test, which showed some ischemia. The cardiologist suggested an angiogram to rule out a probable false-positive result. Now, I really didn’t have time for this, either—but having gone this far, I felt it was important just to get it over with. Thank goodness I did!

During my angiogram (by the way, they give you great LaLa Land drugs), the interventional cardiologist discovered a 95% blockage of the circumflex, a 95% blockage of the right coronary artery, and a 60% blockage of the LAD. The big decision at that point, amidst the obvious shock of my mortality, was whether to opt for an open-heart bypass or stents. I chose stents (which, by the way, have had a significant impact on my energy level). My cardiologist tells me that, without the stents, if I had experienced a total occlusion event, I would not have survived. Quite a sobering thought!

My purpose in sharing this story is not to call attention to myself but rather to offer a wake-up call to those of us who think we are invincible. Many colleagues who have heard my story have decided to get their own long-delayed treadmill or other health-related tests. So here is my call to action to all of you: Take care of your health. The irony is that, for health care providers, this can be difficult.

Those who care for others often have a tough time caring for themselves. We know that physicians are notoriously bad patients, and I think PAs/NPs are no different. We deal with life-and-death issues all the time, and outward displays of distress are, at a minimum, discouraged. In general, our training and accumulated experience help us to develop good coping skills: We are taught to ignore basic human needs (like hunger and fatigue) and to remain capable, competent, and compassionate clinicians under highly stressful conditions.

Nonetheless, we experience these high levels of stress and seldom act to relieve them. As long ago as 1886, Dr William Ogle exposed clinicians’ vulnerability to high mortality risks, but to this day, the subject remains fairly neglected.¹ Perhaps as a result of stigma—we worry about confidentiality, or that our colleagues will consider us inadequate or incompetent clinicians, or that a display of “weakness” means we have failed in some way—we often wait too long to seek treatment. Often, it takes a crisis before we stop to care for ourselves.

Continue for suggestions on how to take care of yourself >>

We promote the health of our patients, but we often forget that if health is to be sustained, those who provide the help must be capable of caring for both themselves and others.² Without being overly prescriptive, I would like to share with you some suggestions for how you can take care of yourself:

1. Maintain a positive attitude. Yes, we often set ourselves up for failure, but we must have patience with ourselves. There are countless ways to practice reflection and find some time to think; it could entail an artistic outlet such as painting, sculpting, sewing, or singing. A colleague of mine listens to affirmations (now available by smartphone app) that she says help her succeed in her daily endeavors.

2. Identify your support systems. You know who they are: family, friends, and colleagues who bring positive support to your life. Spend more time with them. Clinicians with strong family or social connections are generally healthier than those who lack a support network. Make plans with supportive family members and friends, or seek out activities where you can meet new people.

3. Choose healthy, well-balanced meals. This is probably one of the most difficult tasks, due to our hectic and busy lifestyles. We should strive for low-fat, low-sugar, low-salt, high-fiber, and reasonably low-calorie meals. And drink more water—at least 6 to 8 glasses per day.

4. Get an appropriate amount of sleep. Restorative rest is one of the things you can control and should—no, must—give priority to. It is known that sleep is key to competent delivery of care. The National Sleep Foundation suggests seven to nine hours per night for those ages 26 to 64 and seven to eight hours per night for those older than 65.³ (In fact, some studies have suggested an increase in stroke linked to sleeping longer in older age.⁴)

5. Exercise. Schedule time for a sustainable exercise program. Put it on your calendar, and make that the one meeting that is essential. (This is another area in which technology can help, by providing reminders that you need to get up and move.) You don’t have to go to the gym twice a day or run a marathon. Walking for an hour three or four times a week will make a difference; even a 5-minute walk after a stressful meeting can help. Just do it!

6. Schedule time for R&R. Over the past decade, a staggering number of studies have demonstrated that our work performance plummets when we work prolonged periods without a break. Use your vacation time! A recent Harvard Business Review article reported that employees who take vacation are actually more productive.⁵ Make time for yourself—no one else will!

7. Take care of your mental health. Stress is a fact of life. Do what you can to relieve it; develop good coping skills and use them. You may find that keeping a journal in which you can vent your frustrations and fears or taking your dog for a long walk helps to relieve tension. Find what works for you. And make sure to laugh and find the humor in life. Laughter has been shown to boost the immune system and ease pain. It’s a great way to relax!

8. Take care of your physical health. Caring for your body is one of the best things you can do for yourself. Reduce or eliminate risk factors. Please get your routine health promotion procedures done (eg, colonoscopy, Pap smear, mammogram). And when you experience signs of illness, don’t ignore them! Seek advice early for anything out of the ordinary, be it intermittent dizziness, recurrent fatigue, unintended weight loss, feelings of despair—I could go on.

If even a handful of you heed these suggestions, and doing so makes a difference in your health and longevity, then I have completed my mission for this editorial. 

We should be role models for our patients. The societal focus on healthy lifestyles is a challenge for all of us, but the benefits are enormous. I would love to hear from you regarding ways to enhance our physical and mental health and avoid early morbidity or mortality. You can reach me at PAEditor@frontlinemedcom.com.

REFERENCES
1. Woods R. Physician, heal thyself: the health and mortality of Victorian doctors. Soc Hist Med. 1966;9(1):1-30.
2.  Borchardt GL. Role models for health promotion: the challenge for nurses. Nurs Forum. 2000;35(3):29-32.
3. Hershkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1(1):40-43.
4. Leng Y, Cappuccio FP, Wainwright NWJ, et al. Sleep duration and risk of fatal and nonfatal stroke: a prospective study and meta-analysis. Neurology. 2015;84(11):1072-1079.
5. Friedman R. Dear boss: your team wants you to go on vacation. Harvard Bus Rev. June 15, 2015.

The article “How to do a 3-minute diabetic foot exam” (J Fam Pract. 2014;63:646-656) incorrectly stated in Table 4 that chronic venous insufficiency is a high priority indication for referral to a specialist. It is not. The correct indications for this category include: presence of diabetes with a previous history of ulcer, Charcot neuroarthropathy, or lower extremity amputation. This information has been corrected in the online version of the article.

The article “How to do a 3-minute diabetic foot exam” (J Fam Pract. 2014;63:646-656) incorrectly stated in Table 4 that chronic venous insufficiency is a high priority indication for referral to a specialist. It is not. The correct indications for this category include: presence of diabetes with a previous history of ulcer, Charcot neuroarthropathy, or lower extremity amputation. This information has been corrected in the online version of the article.

The article “How to do a 3-minute diabetic foot exam” (J Fam Pract. 2014;63:646-656) incorrectly stated in Table 4 that chronic venous insufficiency is a high priority indication for referral to a specialist. It is not. The correct indications for this category include: presence of diabetes with a previous history of ulcer, Charcot neuroarthropathy, or lower extremity amputation. This information has been corrected in the online version of the article.

In April 1977, shortly after the new American Board of Emergency Medicine (ABEM) was constituted, it adopted the hourglass as its symbol for the unique nature of emergency medicine—a specialty in large part defined by the very brief time in which emergency physicians (EPs) must correctly identify and treat serious, life-threatening conditions. Incorporating the concept of the “golden hour” in which to prevent the irreversible consequences of serious trauma, and the frequently even shorter period to effectively intervene after cardiovascular and neurovascular catastrophes, the hourglass has become a powerful symbol that all emergency physicians are very, very proud of.

In the years since the American Board of Medical Specialties (ABMS) recognized Emergency Medicine as the 23rd specialty, though much about emergency medicine has remained the same, much has also changed. Currently, the time patients spend in EDs throughout the country is all too frequently determined, not by the time required to diagnose and initiate treatment for their illnesses, but by the time required for an inpatient bed to become available or for safe, reliable outpatient care to be arranged. In some hospitals, ED patients who are admitted and require inpatient care or “observation services” continue to be cared for by EPs and ED nurses, while in other hospitals the care and responsibility for such patients is transferred to the appropriate inpatient service—even as the patients remain for hours or days on ED stretchers on the ground floor of the hospital. In some cases, an entire “hospitalization” takes place in the ED.

Similarly, when the specialty of emergency medicine was first established, it faced not only time, but resource-limitations as well. Few CT scanners then were commonly available in close proximity to EDs; afterward, when CT scans did become easily accessible to ED patients and MRI scanners began to appear, no one considered MRI scans to be “ED procedures” because of the time required to complete the studies. This, of course, was before managed-care appeared on the scene and, more recently, Centers for Medicare & Medicaid Services (CMS) began to seriously question the need for some admissions and short hospital stays. The 2013 Rand Research Report on the “Evolving Role of Emergency Departments in the United States” (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf) clearly describes the many other things that emergency medicine now encompasses.

If the venerable hourglass no longer depicts all that emergency medicine has become, is it time to freshen the image or adopt a new symbol? One other extremely significant time-related feature of emergency medicine that has endured is the recognition that the hours during which the human body gets sick or injured are not restricted to typical work hours or work days, and that, as the title of Brian Zink’s book suggests, EPs are trained to care for “Anyone, Anything, Anytime” (Anyone, Anything, Anytime: A History of Emergency Medicine. Philadelphia, PA: Mosby, Inc; 2006). Perhaps, the time has come to add “24/7” to the hourglass symbol. This suggestion is not as frivolous as it may sound, as increasingly federal and state governments and private insurers are using the availability of care 24 hours a day, 7 days a week as a principal characteristic that differentiates emergency medicine, and the higher reimbursement rates it commands, from the care provided by urgent care and “convenient care” centers.

In April 1977, shortly after the new American Board of Emergency Medicine (ABEM) was constituted, it adopted the hourglass as its symbol for the unique nature of emergency medicine—a specialty in large part defined by the very brief time in which emergency physicians (EPs) must correctly identify and treat serious, life-threatening conditions. Incorporating the concept of the “golden hour” in which to prevent the irreversible consequences of serious trauma, and the frequently even shorter period to effectively intervene after cardiovascular and neurovascular catastrophes, the hourglass has become a powerful symbol that all emergency physicians are very, very proud of.

In the years since the American Board of Medical Specialties (ABMS) recognized Emergency Medicine as the 23rd specialty, though much about emergency medicine has remained the same, much has also changed. Currently, the time patients spend in EDs throughout the country is all too frequently determined, not by the time required to diagnose and initiate treatment for their illnesses, but by the time required for an inpatient bed to become available or for safe, reliable outpatient care to be arranged. In some hospitals, ED patients who are admitted and require inpatient care or “observation services” continue to be cared for by EPs and ED nurses, while in other hospitals the care and responsibility for such patients is transferred to the appropriate inpatient service—even as the patients remain for hours or days on ED stretchers on the ground floor of the hospital. In some cases, an entire “hospitalization” takes place in the ED.

Similarly, when the specialty of emergency medicine was first established, it faced not only time, but resource-limitations as well. Few CT scanners then were commonly available in close proximity to EDs; afterward, when CT scans did become easily accessible to ED patients and MRI scanners began to appear, no one considered MRI scans to be “ED procedures” because of the time required to complete the studies. This, of course, was before managed-care appeared on the scene and, more recently, Centers for Medicare & Medicaid Services (CMS) began to seriously question the need for some admissions and short hospital stays. The 2013 Rand Research Report on the “Evolving Role of Emergency Departments in the United States” (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf) clearly describes the many other things that emergency medicine now encompasses.

If the venerable hourglass no longer depicts all that emergency medicine has become, is it time to freshen the image or adopt a new symbol? One other extremely significant time-related feature of emergency medicine that has endured is the recognition that the hours during which the human body gets sick or injured are not restricted to typical work hours or work days, and that, as the title of Brian Zink’s book suggests, EPs are trained to care for “Anyone, Anything, Anytime” (Anyone, Anything, Anytime: A History of Emergency Medicine. Philadelphia, PA: Mosby, Inc; 2006). Perhaps, the time has come to add “24/7” to the hourglass symbol. This suggestion is not as frivolous as it may sound, as increasingly federal and state governments and private insurers are using the availability of care 24 hours a day, 7 days a week as a principal characteristic that differentiates emergency medicine, and the higher reimbursement rates it commands, from the care provided by urgent care and “convenient care” centers.

In April 1977, shortly after the new American Board of Emergency Medicine (ABEM) was constituted, it adopted the hourglass as its symbol for the unique nature of emergency medicine—a specialty in large part defined by the very brief time in which emergency physicians (EPs) must correctly identify and treat serious, life-threatening conditions. Incorporating the concept of the “golden hour” in which to prevent the irreversible consequences of serious trauma, and the frequently even shorter period to effectively intervene after cardiovascular and neurovascular catastrophes, the hourglass has become a powerful symbol that all emergency physicians are very, very proud of.

In the years since the American Board of Medical Specialties (ABMS) recognized Emergency Medicine as the 23rd specialty, though much about emergency medicine has remained the same, much has also changed. Currently, the time patients spend in EDs throughout the country is all too frequently determined, not by the time required to diagnose and initiate treatment for their illnesses, but by the time required for an inpatient bed to become available or for safe, reliable outpatient care to be arranged. In some hospitals, ED patients who are admitted and require inpatient care or “observation services” continue to be cared for by EPs and ED nurses, while in other hospitals the care and responsibility for such patients is transferred to the appropriate inpatient service—even as the patients remain for hours or days on ED stretchers on the ground floor of the hospital. In some cases, an entire “hospitalization” takes place in the ED.

Similarly, when the specialty of emergency medicine was first established, it faced not only time, but resource-limitations as well. Few CT scanners then were commonly available in close proximity to EDs; afterward, when CT scans did become easily accessible to ED patients and MRI scanners began to appear, no one considered MRI scans to be “ED procedures” because of the time required to complete the studies. This, of course, was before managed-care appeared on the scene and, more recently, Centers for Medicare & Medicaid Services (CMS) began to seriously question the need for some admissions and short hospital stays. The 2013 Rand Research Report on the “Evolving Role of Emergency Departments in the United States” (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf) clearly describes the many other things that emergency medicine now encompasses.

If the venerable hourglass no longer depicts all that emergency medicine has become, is it time to freshen the image or adopt a new symbol? One other extremely significant time-related feature of emergency medicine that has endured is the recognition that the hours during which the human body gets sick or injured are not restricted to typical work hours or work days, and that, as the title of Brian Zink’s book suggests, EPs are trained to care for “Anyone, Anything, Anytime” (Anyone, Anything, Anytime: A History of Emergency Medicine. Philadelphia, PA: Mosby, Inc; 2006). Perhaps, the time has come to add “24/7” to the hourglass symbol. This suggestion is not as frivolous as it may sound, as increasingly federal and state governments and private insurers are using the availability of care 24 hours a day, 7 days a week as a principal characteristic that differentiates emergency medicine, and the higher reimbursement rates it commands, from the care provided by urgent care and “convenient care” centers.