Tag Archives: Family Medicine

We Do Not Interrupt Our Patients

Posted on July 5, 2012 by | 8 comments

Joseph Scherger, MD, MPH

Ever notice a patient wince when interrupted describing his or her problem? It is well known that physicians interrupt their patients much of the time and usually within 30 seconds of the start of the visit. One study in Family Medicine showed that residents interrupted patients 12 seconds into a visit 25% of the time (article pdf).  We even teach interruptions as part of “controlling the conversation” and “limiting the agenda” for the visit.

In a practice where there is ample time for visits, there is rarely if ever a need to interrupt a patient. I’m now in such a setting after more than 30 years of brief office visits, and I had to train myself to not interrupt patients. What a great feeling that is! At our practice, we sit back and let every patient finish what he or she has to say. Patients notice this, too, saying they have never had a physician listen to them like we do. We learn things about patients they have not had the chance to share with physicians before.

Since we have an hour for every new patient visit, early in the encounter I ask the patient to tell me his or her story. The patient often asks, “Which story?” I say, “Where were you born and what happened after that?” It is amazing to me how most patients finish this story in about 5 minutes. As a matter of fact, I’m impressed with how brief most patients are when giving their narratives uninterrupted.

Our physicians are now demonstrating an uninterrupted communication style to medical students in their family medicine clerkships. By the time they arrive at our practice, they have already been taught to interrupt patients, so we teach them otherwise. Often, this helps them love family medicine. We look forward to training residents in uninterrupted narrative next year when our residency program starts.

Interrupting patients is a part of the paternalistic culture of medicine where the physician’s time is more important than the patient’s, and the physician knows better than the patient what the problem is. Such paternalism is unprofessional and even dangerous and should not be a part of patient-centered care.

I admire professionals who let people have their say completely. Counselors are very good at this and so are good lawyers, realtors, designers, and many others. Interruptions seem to be mainly a physician behavior.

Visits with patient can be efficient without interruptions. When patients have been given the chance to say everything they want during the visit, they are more receptive to hearing our assessment and recommendations for managing their problems. After all, patients are in charge of their care. Our job is to serve them, respectfully and without interruption.

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The New Resident Work Hours—Are We Training Shift Workers?

Posted on May 29, 2012 by | 7 comments

Joseph Scherger, MD, MPH

Throughout my career, I have been in favor of restrictions on resident work hours. After watching how surgery residents worked in the 1970s, I wanted none

of that “prison sentence.” After choosing family medicine, I found a program with “civilized” work hours. I do not think much learning happens after working 80 hours in a week, and patients do get harmed by residents who are too fatigued to care or use good judgment.

I embraced the 2003 ACGME resident work hour restrictions since they had flexibility but limited the on-duty time to 80 hours a week and guaranteed some days off each month. Residents could still sit with patients who were going through a long labor and delivery process or who were in end-of-life care. These long experiences are some of the most memorable for residents and do not occur too often to cause chronic fatigue. They showed the resident how well they can work under occasional extreme circumstances, a skill that would be valuable in a crisis.

The 2011 ACGME work hour restrictions are much more specific and prohibit the time for any “work shift.” First-year residents may no longer work on any given day more than 16 hours. That means that if the resident is with a woman in labor or at the bedside of a critically ill patient they must end their work and turn the care over to another resident. Second- and third-year residents must do the same after 24 hours and must be able to have a “strategic nap” after 16 hours. Is this the continuity of care of a family physician? No family physician in practice would ever consider such an abandonment of their patient! This is how emergency room physicians work, and I wonder if these new work restrictions will transform family medicine into shift workers.

There is evidence that we become less effective in our clinical judgment after 12 hours of continuous work and certainly after 16 hours. With that being so, we should train for teamwork where another physician joins us in the care of the patients after we become less effective. That would reinforce that we are not superman and should ask for help but would not take us away from the very situations where we may be doing the most good and are having a great learning experience.

I hope our leaders in the ACGME will make an effort to revise the resident work restrictions again to allow for both continuity of care and teamwork, so we can balance both clinical experience and patient safety.

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The Scope of Family Medicine Is Expanding

Posted on May 10, 2012 by | 5 comments

Joseph Scherger, MD, MPH

Many educators are lamenting today that the scope of family medicine is shrinking.

They refer to fewer family physicians working in hospitals and doing procedures. Warren Newton, MD, MPH, chair of the American Board of Family Medicine, recently sent out a letter expressing this concern. Such a grave outlook is dangerous to our specialty at a time when we are struggling to motivate medical students to go in to family medicine.

I think just the opposite. Family medicine today is more complex and expansive in some ways than ever before. Sure, fewer of us are delivering babies and doing hospital medicine, but family medicine is first and foremost a primary care specialty. Primary care is expanding and becoming far more complex in this new age of medical homes and the advanced use of information systems.

The Willard Report that set the stage for the transition from general practice to family medicine called for the creation of a new primary physician. That doctor would be the personal physician to individuals and their families. It is that personal physician role that is the essence of our specialty. New models of primary care, from concierge medicine to team-oriented medical homes to populations of patients, are deeply complex and expansive.

What do I mean? Prevention became part of primary care in the 1970s and continues to expand.  Primary prevention includes all efforts to prevent disease, and since lifestyle causes 50% or more of disease, motivational counseling toward lifestyle change is a new and vital part of being a personal physician. Secondary prevention is the early detection of disease and knowing and applying all aspects of the US Preventive Services Task Force recommendations requires good information systems and skills. Tertiary prevention is the prevention of complications of chronic disease and is far more complex than when I finished residency 30 years ago.

Chronic illness drives about 75% of all health care costs so effective management of these problems is vital to our health care system. The routine visit of a type 2 diabetic patient is far more complex than before and requires much more time. Acute problems are still a major part of family medicine and if we are available to our patients online, we can manage or coordinate care much more efficiently. Relationship-centered care calls on us to know our patients well and provide the counseling services our patients need to deal with what life brings to them, attending to the biopsychosocial and spiritual dimensions of illness.

So, let’s stop this talk about the scope of practice of family medicine shrinking. I am grateful to have more time to take a deep dive with my patients and be their personal physician with much greater complexity and effectiveness than ever before. Let’s train our residents to do the same and show off this rewarding specialty to our students. What can be better than being a family physician?

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