Hitting a Nerve

This time of year the nonclinical medical journals are full of articles with titles like “Make This Your Best Financial Year!”

pinkomelet/Thinkstock

I read them January after January, but each year they remind me less of January 1st and more of February 2nd – Groundhog Day.

It seems you could republish the same article every year and change the title. All of them mention “collect patient copays” and “submit insurance billings promptly.” I had no idea some offices don’t. To me, this is like suggesting I pay my mortgage each month as a financial tip.

They inevitably also talk about improving my “web presence.” Most small practices don’t have an IT department. I’m it here. My modest (and that’s an exaggeration) web page has a 2003 picture of me that I desperately need to update but don’t have the time or expertise to do these days. People seem to think that small practices are wallowing in time and money, but realistically we have neither.

They also highlight all the free things we can do on the web, like a blog or Twitter account, to promote a practice. They fail to realize how much time it takes to regularly write a blog post. Twitter posts from most practices are either tripe such as “Remember – our office will be closed on Christmas!” or links to some recently published study about the importance of diet and exercise.

Besides, in this day and age pretty much anything can be taken as a claim of a doctor-patient relationship. There’s always someone looking to claim your seemingly innocuous blog post constituted harmful medical advice and try to sue you.

Turn my scheduling over to an online program for greater efficiency? No thanks, I’ll leave that to my awesome secretary. After 15 years here, she knows my personality and can quickly screen out people who will be a bad match for me. She also knows our patients and has a good gestalt for figuring how much time certain people will need. This prevents me from getting too far off schedule. She may not be as efficient as an online booking program, but she’s far more valuable. I’ll take quality over quantity any day.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This time of year the nonclinical medical journals are full of articles with titles like “Make This Your Best Financial Year!”

pinkomelet/Thinkstock

I read them January after January, but each year they remind me less of January 1st and more of February 2nd – Groundhog Day.

It seems you could republish the same article every year and change the title. All of them mention “collect patient copays” and “submit insurance billings promptly.” I had no idea some offices don’t. To me, this is like suggesting I pay my mortgage each month as a financial tip.

They inevitably also talk about improving my “web presence.” Most small practices don’t have an IT department. I’m it here. My modest (and that’s an exaggeration) web page has a 2003 picture of me that I desperately need to update but don’t have the time or expertise to do these days. People seem to think that small practices are wallowing in time and money, but realistically we have neither.

They also highlight all the free things we can do on the web, like a blog or Twitter account, to promote a practice. They fail to realize how much time it takes to regularly write a blog post. Twitter posts from most practices are either tripe such as “Remember – our office will be closed on Christmas!” or links to some recently published study about the importance of diet and exercise.

Besides, in this day and age pretty much anything can be taken as a claim of a doctor-patient relationship. There’s always someone looking to claim your seemingly innocuous blog post constituted harmful medical advice and try to sue you.

Turn my scheduling over to an online program for greater efficiency? No thanks, I’ll leave that to my awesome secretary. After 15 years here, she knows my personality and can quickly screen out people who will be a bad match for me. She also knows our patients and has a good gestalt for figuring how much time certain people will need. This prevents me from getting too far off schedule. She may not be as efficient as an online booking program, but she’s far more valuable. I’ll take quality over quantity any day.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This time of year the nonclinical medical journals are full of articles with titles like “Make This Your Best Financial Year!”

pinkomelet/Thinkstock

I read them January after January, but each year they remind me less of January 1st and more of February 2nd – Groundhog Day.

It seems you could republish the same article every year and change the title. All of them mention “collect patient copays” and “submit insurance billings promptly.” I had no idea some offices don’t. To me, this is like suggesting I pay my mortgage each month as a financial tip.

They inevitably also talk about improving my “web presence.” Most small practices don’t have an IT department. I’m it here. My modest (and that’s an exaggeration) web page has a 2003 picture of me that I desperately need to update but don’t have the time or expertise to do these days. People seem to think that small practices are wallowing in time and money, but realistically we have neither.

They also highlight all the free things we can do on the web, like a blog or Twitter account, to promote a practice. They fail to realize how much time it takes to regularly write a blog post. Twitter posts from most practices are either tripe such as “Remember – our office will be closed on Christmas!” or links to some recently published study about the importance of diet and exercise.

Besides, in this day and age pretty much anything can be taken as a claim of a doctor-patient relationship. There’s always someone looking to claim your seemingly innocuous blog post constituted harmful medical advice and try to sue you.

Turn my scheduling over to an online program for greater efficiency? No thanks, I’ll leave that to my awesome secretary. After 15 years here, she knows my personality and can quickly screen out people who will be a bad match for me. She also knows our patients and has a good gestalt for figuring how much time certain people will need. This prevents me from getting too far off schedule. She may not be as efficient as an online booking program, but she’s far more valuable. I’ll take quality over quantity any day.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

During the holiday break I took some time to organize a lot of old family pictures: deleting duplicates, merging those I pulled off my dad’s computer when he died (which was over 5 years ago), importing ones I took with old digital cameras that were in separate folders ... a bunch of stuff. Some were even childhood pics of me that had been scanned into digital formats. Lots of gigabytes. Lots of time spent watching the little “importing” wheel spin.

Jokic/iStock/Getty Images Plus

As I scrolled through them – literally 5,891 pics and 679 videos – I watched as it became more than a bunch of photos. I watched myself grow up, go through medical school, get married, raise a family. My hair went from brown to gray and receding. My kids went from toddlers to young adults about to leave for college.

It was the story of my life. Without meaning to, it’s what the pictures had become.

It was late at night, but I kept scrolling back and forth. My parents, wife, and others aged in front of me.

Looking in the mirror, or seeing others each day, we never notice the slow changes that time brings. You don’t really see it just thumbing through old photos, either.

But here, in the photos app (something entirely undreamed of in my childhood), I was watching it like it was a movie. Even childhood pictures of my parents. Them dating and getting married. Holding me after bringing me home from the hospital.

I’m certainly not the first to have these thoughts, nor will I be the last. We all go through life in a somewhat organized yet haphazard way, and only when looking backward do we really see how far we’ve come ... often realizing we’re past the halfway point.

Not that this is a bad thing. I mean, that’s life on Earth. It has its good and bad, and aging is part of the rules for all of us.

I suppose you could look at this in terms of our profession. We all (or at least most of us) start out as hospital patients. As we get older and become doctors, hopefully we need to see our own kind less often while at the same time seeing others as patients. As time goes by, most of us start to need to see doctors again, and as we retire and stop practicing medicine, we move back toward being patients ourselves.

For me, the pictures bring back memories and strike emotions in the way hearing or reading stories never can. They give new life to long-forgotten thoughts. Happy and sad, but overall a feeling of contentment that, so far, I feel like I’ve done more good than bad, more right than wrong.

I hope I always feel that way.

I hope everyone else does, too.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

During the holiday break I took some time to organize a lot of old family pictures: deleting duplicates, merging those I pulled off my dad’s computer when he died (which was over 5 years ago), importing ones I took with old digital cameras that were in separate folders ... a bunch of stuff. Some were even childhood pics of me that had been scanned into digital formats. Lots of gigabytes. Lots of time spent watching the little “importing” wheel spin.

Jokic/iStock/Getty Images Plus

As I scrolled through them – literally 5,891 pics and 679 videos – I watched as it became more than a bunch of photos. I watched myself grow up, go through medical school, get married, raise a family. My hair went from brown to gray and receding. My kids went from toddlers to young adults about to leave for college.

It was the story of my life. Without meaning to, it’s what the pictures had become.

It was late at night, but I kept scrolling back and forth. My parents, wife, and others aged in front of me.

Looking in the mirror, or seeing others each day, we never notice the slow changes that time brings. You don’t really see it just thumbing through old photos, either.

But here, in the photos app (something entirely undreamed of in my childhood), I was watching it like it was a movie. Even childhood pictures of my parents. Them dating and getting married. Holding me after bringing me home from the hospital.

I’m certainly not the first to have these thoughts, nor will I be the last. We all go through life in a somewhat organized yet haphazard way, and only when looking backward do we really see how far we’ve come ... often realizing we’re past the halfway point.

Not that this is a bad thing. I mean, that’s life on Earth. It has its good and bad, and aging is part of the rules for all of us.

I suppose you could look at this in terms of our profession. We all (or at least most of us) start out as hospital patients. As we get older and become doctors, hopefully we need to see our own kind less often while at the same time seeing others as patients. As time goes by, most of us start to need to see doctors again, and as we retire and stop practicing medicine, we move back toward being patients ourselves.

For me, the pictures bring back memories and strike emotions in the way hearing or reading stories never can. They give new life to long-forgotten thoughts. Happy and sad, but overall a feeling of contentment that, so far, I feel like I’ve done more good than bad, more right than wrong.

I hope I always feel that way.

I hope everyone else does, too.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

During the holiday break I took some time to organize a lot of old family pictures: deleting duplicates, merging those I pulled off my dad’s computer when he died (which was over 5 years ago), importing ones I took with old digital cameras that were in separate folders ... a bunch of stuff. Some were even childhood pics of me that had been scanned into digital formats. Lots of gigabytes. Lots of time spent watching the little “importing” wheel spin.

Jokic/iStock/Getty Images Plus

As I scrolled through them – literally 5,891 pics and 679 videos – I watched as it became more than a bunch of photos. I watched myself grow up, go through medical school, get married, raise a family. My hair went from brown to gray and receding. My kids went from toddlers to young adults about to leave for college.

It was the story of my life. Without meaning to, it’s what the pictures had become.

It was late at night, but I kept scrolling back and forth. My parents, wife, and others aged in front of me.

Looking in the mirror, or seeing others each day, we never notice the slow changes that time brings. You don’t really see it just thumbing through old photos, either.

But here, in the photos app (something entirely undreamed of in my childhood), I was watching it like it was a movie. Even childhood pictures of my parents. Them dating and getting married. Holding me after bringing me home from the hospital.

I’m certainly not the first to have these thoughts, nor will I be the last. We all go through life in a somewhat organized yet haphazard way, and only when looking backward do we really see how far we’ve come ... often realizing we’re past the halfway point.

Not that this is a bad thing. I mean, that’s life on Earth. It has its good and bad, and aging is part of the rules for all of us.

I suppose you could look at this in terms of our profession. We all (or at least most of us) start out as hospital patients. As we get older and become doctors, hopefully we need to see our own kind less often while at the same time seeing others as patients. As time goes by, most of us start to need to see doctors again, and as we retire and stop practicing medicine, we move back toward being patients ourselves.

For me, the pictures bring back memories and strike emotions in the way hearing or reading stories never can. They give new life to long-forgotten thoughts. Happy and sad, but overall a feeling of contentment that, so far, I feel like I’ve done more good than bad, more right than wrong.

I hope I always feel that way.

I hope everyone else does, too.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’ll put up with a lot in this practice, but I will not tolerate mistreatment of my staff.

ALLVISIONN/Thinkstock

Rudeness, while never pleasant, is generally tolerated. Some people just have that sort of personality. Others may be having a crappy day for unrelated reasons. We all have those.

But those who are intentionally abusive of my hardworking assistants aren’t going to get very far here. I have no problem telling them to go elsewhere. (This doesn’t include those with neurologic reasons for such behavior.)

Some doctors are more willing to put up with this than I am. I once shared space with one who routinely told his staff to ignore abusive behaviors. He didn’t want to turn away any potential revenue or risk angering a referring doctor.

I take another view. Life is short, and medical practice is, by nature, hectic. I have little enough time to care for the patients who genuinely appreciate what my staff and I are trying to do for them. People who are abusive and belligerent can find another doctor who’s willing to put up with it. I won’t.

My staff and I don’t expect to be thanked. We all signed up to work here. But we also try to treat patients with concern and respect, and ask the same courtesy in return. Isn’t that the golden rule?

Abusive patients are difficult to deal with, time consuming, and contribute to staff burnout. The two awesome women who work here deserve better than that. If they’re not happy, I’m not happy. All it takes is one bad person to throw the day off kilter and sometimes affect the care of the next patient in line. That person deserves better, too.

Some will argue that, as a doctor, I should care for all who need my help. In the hospital, I do. I understand that people there generally are scared and hurting and do not want to be there. But in my office I expect at least some degree of civility. We have to be at our best for each person who comes in, and having patients we can work with on a polite level helps.

There’s enough insanity in this job on a good day. People who intentionally try to make it worse aren’t welcome in my little world.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’ll put up with a lot in this practice, but I will not tolerate mistreatment of my staff.

ALLVISIONN/Thinkstock

Rudeness, while never pleasant, is generally tolerated. Some people just have that sort of personality. Others may be having a crappy day for unrelated reasons. We all have those.

But those who are intentionally abusive of my hardworking assistants aren’t going to get very far here. I have no problem telling them to go elsewhere. (This doesn’t include those with neurologic reasons for such behavior.)

Some doctors are more willing to put up with this than I am. I once shared space with one who routinely told his staff to ignore abusive behaviors. He didn’t want to turn away any potential revenue or risk angering a referring doctor.

I take another view. Life is short, and medical practice is, by nature, hectic. I have little enough time to care for the patients who genuinely appreciate what my staff and I are trying to do for them. People who are abusive and belligerent can find another doctor who’s willing to put up with it. I won’t.

My staff and I don’t expect to be thanked. We all signed up to work here. But we also try to treat patients with concern and respect, and ask the same courtesy in return. Isn’t that the golden rule?

Abusive patients are difficult to deal with, time consuming, and contribute to staff burnout. The two awesome women who work here deserve better than that. If they’re not happy, I’m not happy. All it takes is one bad person to throw the day off kilter and sometimes affect the care of the next patient in line. That person deserves better, too.

Some will argue that, as a doctor, I should care for all who need my help. In the hospital, I do. I understand that people there generally are scared and hurting and do not want to be there. But in my office I expect at least some degree of civility. We have to be at our best for each person who comes in, and having patients we can work with on a polite level helps.

There’s enough insanity in this job on a good day. People who intentionally try to make it worse aren’t welcome in my little world.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’ll put up with a lot in this practice, but I will not tolerate mistreatment of my staff.

ALLVISIONN/Thinkstock

Rudeness, while never pleasant, is generally tolerated. Some people just have that sort of personality. Others may be having a crappy day for unrelated reasons. We all have those.

But those who are intentionally abusive of my hardworking assistants aren’t going to get very far here. I have no problem telling them to go elsewhere. (This doesn’t include those with neurologic reasons for such behavior.)

Some doctors are more willing to put up with this than I am. I once shared space with one who routinely told his staff to ignore abusive behaviors. He didn’t want to turn away any potential revenue or risk angering a referring doctor.

I take another view. Life is short, and medical practice is, by nature, hectic. I have little enough time to care for the patients who genuinely appreciate what my staff and I are trying to do for them. People who are abusive and belligerent can find another doctor who’s willing to put up with it. I won’t.

My staff and I don’t expect to be thanked. We all signed up to work here. But we also try to treat patients with concern and respect, and ask the same courtesy in return. Isn’t that the golden rule?

Abusive patients are difficult to deal with, time consuming, and contribute to staff burnout. The two awesome women who work here deserve better than that. If they’re not happy, I’m not happy. All it takes is one bad person to throw the day off kilter and sometimes affect the care of the next patient in line. That person deserves better, too.

Some will argue that, as a doctor, I should care for all who need my help. In the hospital, I do. I understand that people there generally are scared and hurting and do not want to be there. But in my office I expect at least some degree of civility. We have to be at our best for each person who comes in, and having patients we can work with on a polite level helps.

There’s enough insanity in this job on a good day. People who intentionally try to make it worse aren’t welcome in my little world.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m getting old and starting to fall apart. Recently, I suffered a lumbar radiculopathy when I injured myself sneezing. (No, really, I did.)

lolostock/Thinkstock

So, as time went by and I didn’t get better, I began looking stuff up. When patients come to me for this, I go through the standard conservative regimen of NSAIDs, physical therapy, steroid tapers ... the standard stuff.

But, when I began looking these things up, I was surprised to find out how much of what we do (at least for lumbar radiculopathy) is taken on faith.

I went through UpToDate, the modern Bible of medicine.

NSAIDs and acetaminophen, to my surprise, have only marginal proof of efficacy for acute lumbosacral radiculopathy pain. Several pooled analyses showed a nonsignificant trend to support their use, and the quality of the data was considered to be low.

Likewise, physical therapy also had “no convincing evidence that such treatments are effective for this indication.” Admittedly, some of the data may be affected by the difficulty in doing sham therapy as part of a placebo controlled-trial.

An oral steroid taper? Again, similar, equivocal data. Marginal improvement in functional capabilities, no improvement in pain, and no improvement in the rate of surgery at 1 year out.

But these are the things that I, and likely most family doctors, physiatrists, and other neurologists recommend on a daily basis. And, in all likelihood, will continue to do so.

Why?

Overall, they are benign when used correctly and in the right patients. That isn’t to say everyone should get them. All drugs have issues, and patients have to be carefully matched to specific treatments.

But, in the grand scheme of “do no harm,” physical therapy, NSAIDs, acetaminophen, or a few days of steroids are reasonably harmless. There certainly are some patients who will benefit, and none of these approaches have clearly been shown to be dangerous.

There’s also patient expectations. They didn’t come to us, or shell out a copay, to be told that “nothing helps, give it time.” We’re the doctors, and they want us to DO SOMETHING. So even if these treatments may be placebos, they still help if for no other reason than (as Voltaire said) to amuse the patient while nature cures the disease.

And getting them better is, after all, a big part of our job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m getting old and starting to fall apart. Recently, I suffered a lumbar radiculopathy when I injured myself sneezing. (No, really, I did.)

lolostock/Thinkstock

So, as time went by and I didn’t get better, I began looking stuff up. When patients come to me for this, I go through the standard conservative regimen of NSAIDs, physical therapy, steroid tapers ... the standard stuff.

But, when I began looking these things up, I was surprised to find out how much of what we do (at least for lumbar radiculopathy) is taken on faith.

I went through UpToDate, the modern Bible of medicine.

NSAIDs and acetaminophen, to my surprise, have only marginal proof of efficacy for acute lumbosacral radiculopathy pain. Several pooled analyses showed a nonsignificant trend to support their use, and the quality of the data was considered to be low.

Likewise, physical therapy also had “no convincing evidence that such treatments are effective for this indication.” Admittedly, some of the data may be affected by the difficulty in doing sham therapy as part of a placebo controlled-trial.

An oral steroid taper? Again, similar, equivocal data. Marginal improvement in functional capabilities, no improvement in pain, and no improvement in the rate of surgery at 1 year out.

But these are the things that I, and likely most family doctors, physiatrists, and other neurologists recommend on a daily basis. And, in all likelihood, will continue to do so.

Why?

Overall, they are benign when used correctly and in the right patients. That isn’t to say everyone should get them. All drugs have issues, and patients have to be carefully matched to specific treatments.

But, in the grand scheme of “do no harm,” physical therapy, NSAIDs, acetaminophen, or a few days of steroids are reasonably harmless. There certainly are some patients who will benefit, and none of these approaches have clearly been shown to be dangerous.

There’s also patient expectations. They didn’t come to us, or shell out a copay, to be told that “nothing helps, give it time.” We’re the doctors, and they want us to DO SOMETHING. So even if these treatments may be placebos, they still help if for no other reason than (as Voltaire said) to amuse the patient while nature cures the disease.

And getting them better is, after all, a big part of our job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m getting old and starting to fall apart. Recently, I suffered a lumbar radiculopathy when I injured myself sneezing. (No, really, I did.)

lolostock/Thinkstock

So, as time went by and I didn’t get better, I began looking stuff up. When patients come to me for this, I go through the standard conservative regimen of NSAIDs, physical therapy, steroid tapers ... the standard stuff.

But, when I began looking these things up, I was surprised to find out how much of what we do (at least for lumbar radiculopathy) is taken on faith.

I went through UpToDate, the modern Bible of medicine.

NSAIDs and acetaminophen, to my surprise, have only marginal proof of efficacy for acute lumbosacral radiculopathy pain. Several pooled analyses showed a nonsignificant trend to support their use, and the quality of the data was considered to be low.

Likewise, physical therapy also had “no convincing evidence that such treatments are effective for this indication.” Admittedly, some of the data may be affected by the difficulty in doing sham therapy as part of a placebo controlled-trial.

An oral steroid taper? Again, similar, equivocal data. Marginal improvement in functional capabilities, no improvement in pain, and no improvement in the rate of surgery at 1 year out.

But these are the things that I, and likely most family doctors, physiatrists, and other neurologists recommend on a daily basis. And, in all likelihood, will continue to do so.

Why?

Overall, they are benign when used correctly and in the right patients. That isn’t to say everyone should get them. All drugs have issues, and patients have to be carefully matched to specific treatments.

But, in the grand scheme of “do no harm,” physical therapy, NSAIDs, acetaminophen, or a few days of steroids are reasonably harmless. There certainly are some patients who will benefit, and none of these approaches have clearly been shown to be dangerous.

There’s also patient expectations. They didn’t come to us, or shell out a copay, to be told that “nothing helps, give it time.” We’re the doctors, and they want us to DO SOMETHING. So even if these treatments may be placebos, they still help if for no other reason than (as Voltaire said) to amuse the patient while nature cures the disease.

And getting them better is, after all, a big part of our job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In the October 2018 issue of Medscape Business of Medicine, the question was asked, “How can you practice quality medicine if you’re being asked to see patients every 15 minutes or less?”

CherriesJD/Thinkstock

I’m pretty sure the answer is, “you can’t.”

Yet, this is what many doctors are asked to do just to make ends meet. The majority of everyday medicine is, and always will be, a thinking game. It takes time to piece together the clues from a history and exam and decide what tests and/or treatment are the next step.

This ain’t easy. Even the shortest residencies require a combined 7 years of medical school and postgrad training. Experience and learning makes us all faster, but then the number of things that you can handle in 15 minutes is minimal. And that doesn’t even include the time needed to answer patient or family questions (which can be quite a lot) write up or transmit test orders or a prescription, and, inevitably, document the entire encounter in a meaningful way.

I don’t see patients at such a breakneck speed in my office, and yet I still end up doing most of my dictations after (or before) office hours.

In spite of lip service by politicians and administrators to correct the issue, medicine still continues to penalize those services that require thinking. And this task is the center of being a good doctor – and always has been.

Procedures are more lucrative, but imagine how my colleagues in neurosurgery would react if they were given a similar time limit on cases: A new patient has to be on the table every 15-30 minutes, and in that time you have to open, do the surgery, close, meet with family, and document the whole thing. Then get back in the OR (scrub, first) before the next case. Doesn’t matter whether you’re doing a lumbar fusion, glioma resection, or carotid endarterectomy. Those are the time limits. You get 30 minutes for lunch and to return calls. The administrator said so.

And this is where medicine continues to go. Overhead costs keep rising, and, for most docs, the only way they know to keep up is to keep cramming more patients into the day. Nobody wants to practice shoddy, hurried medicine, but neither do they want to lose their jobs to the next hungry graduate or close down a practice they spent years building.

I wish I had an answer. In fact, I think most of us do, but not one that will make patients, administrators, and doctors all happy. So the spiral continues.

And that isn’t good for patients, the people at the center of this job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In the October 2018 issue of Medscape Business of Medicine, the question was asked, “How can you practice quality medicine if you’re being asked to see patients every 15 minutes or less?”

CherriesJD/Thinkstock

I’m pretty sure the answer is, “you can’t.”

Yet, this is what many doctors are asked to do just to make ends meet. The majority of everyday medicine is, and always will be, a thinking game. It takes time to piece together the clues from a history and exam and decide what tests and/or treatment are the next step.

This ain’t easy. Even the shortest residencies require a combined 7 years of medical school and postgrad training. Experience and learning makes us all faster, but then the number of things that you can handle in 15 minutes is minimal. And that doesn’t even include the time needed to answer patient or family questions (which can be quite a lot) write up or transmit test orders or a prescription, and, inevitably, document the entire encounter in a meaningful way.

I don’t see patients at such a breakneck speed in my office, and yet I still end up doing most of my dictations after (or before) office hours.

In spite of lip service by politicians and administrators to correct the issue, medicine still continues to penalize those services that require thinking. And this task is the center of being a good doctor – and always has been.

Procedures are more lucrative, but imagine how my colleagues in neurosurgery would react if they were given a similar time limit on cases: A new patient has to be on the table every 15-30 minutes, and in that time you have to open, do the surgery, close, meet with family, and document the whole thing. Then get back in the OR (scrub, first) before the next case. Doesn’t matter whether you’re doing a lumbar fusion, glioma resection, or carotid endarterectomy. Those are the time limits. You get 30 minutes for lunch and to return calls. The administrator said so.

And this is where medicine continues to go. Overhead costs keep rising, and, for most docs, the only way they know to keep up is to keep cramming more patients into the day. Nobody wants to practice shoddy, hurried medicine, but neither do they want to lose their jobs to the next hungry graduate or close down a practice they spent years building.

I wish I had an answer. In fact, I think most of us do, but not one that will make patients, administrators, and doctors all happy. So the spiral continues.

And that isn’t good for patients, the people at the center of this job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In the October 2018 issue of Medscape Business of Medicine, the question was asked, “How can you practice quality medicine if you’re being asked to see patients every 15 minutes or less?”

CherriesJD/Thinkstock

I’m pretty sure the answer is, “you can’t.”

Yet, this is what many doctors are asked to do just to make ends meet. The majority of everyday medicine is, and always will be, a thinking game. It takes time to piece together the clues from a history and exam and decide what tests and/or treatment are the next step.

This ain’t easy. Even the shortest residencies require a combined 7 years of medical school and postgrad training. Experience and learning makes us all faster, but then the number of things that you can handle in 15 minutes is minimal. And that doesn’t even include the time needed to answer patient or family questions (which can be quite a lot) write up or transmit test orders or a prescription, and, inevitably, document the entire encounter in a meaningful way.

I don’t see patients at such a breakneck speed in my office, and yet I still end up doing most of my dictations after (or before) office hours.

In spite of lip service by politicians and administrators to correct the issue, medicine still continues to penalize those services that require thinking. And this task is the center of being a good doctor – and always has been.

Procedures are more lucrative, but imagine how my colleagues in neurosurgery would react if they were given a similar time limit on cases: A new patient has to be on the table every 15-30 minutes, and in that time you have to open, do the surgery, close, meet with family, and document the whole thing. Then get back in the OR (scrub, first) before the next case. Doesn’t matter whether you’re doing a lumbar fusion, glioma resection, or carotid endarterectomy. Those are the time limits. You get 30 minutes for lunch and to return calls. The administrator said so.

And this is where medicine continues to go. Overhead costs keep rising, and, for most docs, the only way they know to keep up is to keep cramming more patients into the day. Nobody wants to practice shoddy, hurried medicine, but neither do they want to lose their jobs to the next hungry graduate or close down a practice they spent years building.

I wish I had an answer. In fact, I think most of us do, but not one that will make patients, administrators, and doctors all happy. So the spiral continues.

And that isn’t good for patients, the people at the center of this job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

When I first began practice the COX-2 inhibitors had first come to market. My sample closet was awash with Celebrex and Vioxx.

Denise Fulton/MDedge News

I was young and naive. These drugs were allegedly safer than NSAIDs, so shouldn’t I be using them? They were new, and therefore had to be better, than plain old naproxen and ibuprofen. And hey, the samples were free.

As a result, I handed them out for pretty much all musculoskeletal stuff. “Here, try this ... ”

Of course, that came to a crashing halt when I encountered the realities of payers and drug coverage. No history of GI issues, no previous tries/fails ... Why on earth are you prescribing this? Obviously, the answer “because the samples were free” wasn’t going to pass muster.

Granted, history wasn’t particularly kind to the COX-2 drugs. Out of the three that made it to market, two were withdrawn and Celebrex’s star faded with them. But the lesson is still there.

Today, 20 years later, I use more generics. Maybe it’s because I’m familiar with them (many came to market during my career). Maybe it’s because years of calls from patients, pharmacies, and insurance companies have taught me to try them first. Probably a mixture of both.

This isn’t to say I don’t use branded drugs. I prescribe my share. There are plenty of times a generic isn’t appropriate, or a new approach is needed after a treatment failure.

But I’ve also learned that the sample closet is never a good basis for medical decisions.

We learn a lot about the many different medications available in medical school and residency. But learning facts about dosing, side effects, and mechanisms of action (while quite important) is quite different from the practical aspect of learning what is more likely to be covered and affordable. Only the experience of everyday practice will teach that.

It sure taught me.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

When I first began practice the COX-2 inhibitors had first come to market. My sample closet was awash with Celebrex and Vioxx.

Denise Fulton/MDedge News

I was young and naive. These drugs were allegedly safer than NSAIDs, so shouldn’t I be using them? They were new, and therefore had to be better, than plain old naproxen and ibuprofen. And hey, the samples were free.

As a result, I handed them out for pretty much all musculoskeletal stuff. “Here, try this ... ”

Of course, that came to a crashing halt when I encountered the realities of payers and drug coverage. No history of GI issues, no previous tries/fails ... Why on earth are you prescribing this? Obviously, the answer “because the samples were free” wasn’t going to pass muster.

Granted, history wasn’t particularly kind to the COX-2 drugs. Out of the three that made it to market, two were withdrawn and Celebrex’s star faded with them. But the lesson is still there.

Today, 20 years later, I use more generics. Maybe it’s because I’m familiar with them (many came to market during my career). Maybe it’s because years of calls from patients, pharmacies, and insurance companies have taught me to try them first. Probably a mixture of both.

This isn’t to say I don’t use branded drugs. I prescribe my share. There are plenty of times a generic isn’t appropriate, or a new approach is needed after a treatment failure.

But I’ve also learned that the sample closet is never a good basis for medical decisions.

We learn a lot about the many different medications available in medical school and residency. But learning facts about dosing, side effects, and mechanisms of action (while quite important) is quite different from the practical aspect of learning what is more likely to be covered and affordable. Only the experience of everyday practice will teach that.

It sure taught me.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

When I first began practice the COX-2 inhibitors had first come to market. My sample closet was awash with Celebrex and Vioxx.

Denise Fulton/MDedge News

I was young and naive. These drugs were allegedly safer than NSAIDs, so shouldn’t I be using them? They were new, and therefore had to be better, than plain old naproxen and ibuprofen. And hey, the samples were free.

As a result, I handed them out for pretty much all musculoskeletal stuff. “Here, try this ... ”

Of course, that came to a crashing halt when I encountered the realities of payers and drug coverage. No history of GI issues, no previous tries/fails ... Why on earth are you prescribing this? Obviously, the answer “because the samples were free” wasn’t going to pass muster.

Granted, history wasn’t particularly kind to the COX-2 drugs. Out of the three that made it to market, two were withdrawn and Celebrex’s star faded with them. But the lesson is still there.

Today, 20 years later, I use more generics. Maybe it’s because I’m familiar with them (many came to market during my career). Maybe it’s because years of calls from patients, pharmacies, and insurance companies have taught me to try them first. Probably a mixture of both.

This isn’t to say I don’t use branded drugs. I prescribe my share. There are plenty of times a generic isn’t appropriate, or a new approach is needed after a treatment failure.

But I’ve also learned that the sample closet is never a good basis for medical decisions.

We learn a lot about the many different medications available in medical school and residency. But learning facts about dosing, side effects, and mechanisms of action (while quite important) is quite different from the practical aspect of learning what is more likely to be covered and affordable. Only the experience of everyday practice will teach that.

It sure taught me.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

About a year ago, I had a patient come in who didn’t like me.

It seemed like a normal visit. My secretary had him fill out the usual forms and copied his insurance cards, and I took him back to my office. We do this many times, every day.

He came back to my office, and I asked him what brought him to my care.

Instead of starting his medical history, though, he immediately gave me a long list of complaints. He didn’t like my appearance. Or my secretary. Or my forms. Or us asking if he’d had any previous tests. Or the parking at my office. Or the phone system. Or a coffee stain in my building’s elevator carpeting.

A whole list of stuff, none actually related to his reason for coming in. I let him rant for a minute, thinking maybe he’d get to the point, but he just kept getting angrier and bringing up more grievances.

I finally interrupted him and said, “Sir, if you’re unhappy with me, you are welcome to end the appointment and leave now.” He told me he wasn’t going to pay for the visit (not that I would have charged him for it) and stomped out. My secretary shredded his info. There’s always other stuff that needs my attention, so I busied myself with that until the next appointment arrived.

Twenty years ago this probably would have really upset me. But today? Not at all.

Like most other doctors, I want to help people. I enjoy doing that. It’s why I’m here. But I’ve also learned that there are some people I’ll never be able to work with under any circumstances. Some will just never like me as a physician, my casual appearance, or small practice.

People like this guy happen a few times a year. Experience teaches that you can’t be everyone’s doctor, can’t make everyone happy, and can’t have them all like you. If they don’t, that’s part of life. You can’t predict interpersonal chemistry and worrying about such things isn’t good for your blood pressure. You can’t change others.

Ironically, the same gentleman called recently, saying he needed to get in with me now. My secretary called him back, reminded him of what happened last year and suggested he go elsewhere.

His response? “I didn’t like your office then and still don’t.”

I’m okay with that. You can’t please everyone. Sometimes it’s not even worth trying.

 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

About a year ago, I had a patient come in who didn’t like me.

It seemed like a normal visit. My secretary had him fill out the usual forms and copied his insurance cards, and I took him back to my office. We do this many times, every day.

He came back to my office, and I asked him what brought him to my care.

Instead of starting his medical history, though, he immediately gave me a long list of complaints. He didn’t like my appearance. Or my secretary. Or my forms. Or us asking if he’d had any previous tests. Or the parking at my office. Or the phone system. Or a coffee stain in my building’s elevator carpeting.

A whole list of stuff, none actually related to his reason for coming in. I let him rant for a minute, thinking maybe he’d get to the point, but he just kept getting angrier and bringing up more grievances.

I finally interrupted him and said, “Sir, if you’re unhappy with me, you are welcome to end the appointment and leave now.” He told me he wasn’t going to pay for the visit (not that I would have charged him for it) and stomped out. My secretary shredded his info. There’s always other stuff that needs my attention, so I busied myself with that until the next appointment arrived.

Twenty years ago this probably would have really upset me. But today? Not at all.

Like most other doctors, I want to help people. I enjoy doing that. It’s why I’m here. But I’ve also learned that there are some people I’ll never be able to work with under any circumstances. Some will just never like me as a physician, my casual appearance, or small practice.

People like this guy happen a few times a year. Experience teaches that you can’t be everyone’s doctor, can’t make everyone happy, and can’t have them all like you. If they don’t, that’s part of life. You can’t predict interpersonal chemistry and worrying about such things isn’t good for your blood pressure. You can’t change others.

Ironically, the same gentleman called recently, saying he needed to get in with me now. My secretary called him back, reminded him of what happened last year and suggested he go elsewhere.

His response? “I didn’t like your office then and still don’t.”

I’m okay with that. You can’t please everyone. Sometimes it’s not even worth trying.

 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

About a year ago, I had a patient come in who didn’t like me.

It seemed like a normal visit. My secretary had him fill out the usual forms and copied his insurance cards, and I took him back to my office. We do this many times, every day.

He came back to my office, and I asked him what brought him to my care.

Instead of starting his medical history, though, he immediately gave me a long list of complaints. He didn’t like my appearance. Or my secretary. Or my forms. Or us asking if he’d had any previous tests. Or the parking at my office. Or the phone system. Or a coffee stain in my building’s elevator carpeting.

A whole list of stuff, none actually related to his reason for coming in. I let him rant for a minute, thinking maybe he’d get to the point, but he just kept getting angrier and bringing up more grievances.

I finally interrupted him and said, “Sir, if you’re unhappy with me, you are welcome to end the appointment and leave now.” He told me he wasn’t going to pay for the visit (not that I would have charged him for it) and stomped out. My secretary shredded his info. There’s always other stuff that needs my attention, so I busied myself with that until the next appointment arrived.

Twenty years ago this probably would have really upset me. But today? Not at all.

Like most other doctors, I want to help people. I enjoy doing that. It’s why I’m here. But I’ve also learned that there are some people I’ll never be able to work with under any circumstances. Some will just never like me as a physician, my casual appearance, or small practice.

People like this guy happen a few times a year. Experience teaches that you can’t be everyone’s doctor, can’t make everyone happy, and can’t have them all like you. If they don’t, that’s part of life. You can’t predict interpersonal chemistry and worrying about such things isn’t good for your blood pressure. You can’t change others.

Ironically, the same gentleman called recently, saying he needed to get in with me now. My secretary called him back, reminded him of what happened last year and suggested he go elsewhere.

His response? “I didn’t like your office then and still don’t.”

I’m okay with that. You can’t please everyone. Sometimes it’s not even worth trying.

 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Why do patients no-show?

The reasons are, obviously, widely variable among patients and circumstances. Some are more understandable than others, but all of them add up to an empty chair across the desk and loss of income for that time slot.

CherriesJD/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Why do patients no-show?

The reasons are, obviously, widely variable among patients and circumstances. Some are more understandable than others, but all of them add up to an empty chair across the desk and loss of income for that time slot.

CherriesJD/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Why do patients no-show?

The reasons are, obviously, widely variable among patients and circumstances. Some are more understandable than others, but all of them add up to an empty chair across the desk and loss of income for that time slot.

CherriesJD/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The frontal lobes are pretty important. They help us plan and concentrate, and they keep us from being impulsive and distracted. They help to override those pesky emotions that can interfere with objective thought.

In Vulcans, I imagine, the frontal lobes are huge.

We put a lot of faith into them in this field. We have to stay calm and try to reason during stressful times, often with people who aren’t quite as clear headed at that moment.

Gilitukha/Thinkstock

I think we all like to believe we’re creatures of our intellects: able to think dispassionately about the current case in front of us, to make decisions based on established facts and data. And, generally, most of us do a good job.

But sometimes it doesn’t work that way.

One day in late July, I was working my way through the usual afternoon patients at the office, checking test results, making decisions – the everyday stuff. After 20 years, this has become routine.

At 1:48, while talking to a patient, an email crossed my screen. As usual, I glanced at it to make sure it wasn’t a patient emergency ... nope. It was mine.

Because of a rapidly moving forest fire in southern California, my daughter’s summer camp was being evacuated. She was safe, but they were being moved to a high school that was being used as an evacuation center in Banning, Calif. We were asked to come get her as soon as safely possible.

And, just like that, my frontal lobes got moved to the back seat.

Granted, I didn’t panic. I didn’t cancel the patients I had waiting. I completed my current appointment, then took a few extra minutes to look at the schedule with my secretary to see where we could move the next day’s patients so I could drive to California in the morning. Then I went on with my day.

I still had three more patients left. Although none of them said anything, I’m sure they noticed I wasn’t mentally all there. I probably seemed distracted, checking my screen a few more times than I should have to see whether there were further updates. I don’t think I made any bad decisions about treatment, but I certainly wasn’t at the top of my game. A few days later, after things had settled down, I reread my notes from the day to make sure I hadn’t missed anything.

It’s a surprising reminder of how powerful the older, nonrational parts of our brains are. Although they didn’t take over, they certainly affected my ability to focus on the task at hand. There’s a reason those areas exist, too, even if we keep them hidden in our daily lives.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The frontal lobes are pretty important. They help us plan and concentrate, and they keep us from being impulsive and distracted. They help to override those pesky emotions that can interfere with objective thought.

In Vulcans, I imagine, the frontal lobes are huge.

We put a lot of faith into them in this field. We have to stay calm and try to reason during stressful times, often with people who aren’t quite as clear headed at that moment.

Gilitukha/Thinkstock

I think we all like to believe we’re creatures of our intellects: able to think dispassionately about the current case in front of us, to make decisions based on established facts and data. And, generally, most of us do a good job.

But sometimes it doesn’t work that way.

One day in late July, I was working my way through the usual afternoon patients at the office, checking test results, making decisions – the everyday stuff. After 20 years, this has become routine.

At 1:48, while talking to a patient, an email crossed my screen. As usual, I glanced at it to make sure it wasn’t a patient emergency ... nope. It was mine.

Because of a rapidly moving forest fire in southern California, my daughter’s summer camp was being evacuated. She was safe, but they were being moved to a high school that was being used as an evacuation center in Banning, Calif. We were asked to come get her as soon as safely possible.

And, just like that, my frontal lobes got moved to the back seat.

Granted, I didn’t panic. I didn’t cancel the patients I had waiting. I completed my current appointment, then took a few extra minutes to look at the schedule with my secretary to see where we could move the next day’s patients so I could drive to California in the morning. Then I went on with my day.

I still had three more patients left. Although none of them said anything, I’m sure they noticed I wasn’t mentally all there. I probably seemed distracted, checking my screen a few more times than I should have to see whether there were further updates. I don’t think I made any bad decisions about treatment, but I certainly wasn’t at the top of my game. A few days later, after things had settled down, I reread my notes from the day to make sure I hadn’t missed anything.

It’s a surprising reminder of how powerful the older, nonrational parts of our brains are. Although they didn’t take over, they certainly affected my ability to focus on the task at hand. There’s a reason those areas exist, too, even if we keep them hidden in our daily lives.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The frontal lobes are pretty important. They help us plan and concentrate, and they keep us from being impulsive and distracted. They help to override those pesky emotions that can interfere with objective thought.

In Vulcans, I imagine, the frontal lobes are huge.

We put a lot of faith into them in this field. We have to stay calm and try to reason during stressful times, often with people who aren’t quite as clear headed at that moment.

Gilitukha/Thinkstock

I think we all like to believe we’re creatures of our intellects: able to think dispassionately about the current case in front of us, to make decisions based on established facts and data. And, generally, most of us do a good job.

But sometimes it doesn’t work that way.

One day in late July, I was working my way through the usual afternoon patients at the office, checking test results, making decisions – the everyday stuff. After 20 years, this has become routine.

At 1:48, while talking to a patient, an email crossed my screen. As usual, I glanced at it to make sure it wasn’t a patient emergency ... nope. It was mine.

Because of a rapidly moving forest fire in southern California, my daughter’s summer camp was being evacuated. She was safe, but they were being moved to a high school that was being used as an evacuation center in Banning, Calif. We were asked to come get her as soon as safely possible.

And, just like that, my frontal lobes got moved to the back seat.

Granted, I didn’t panic. I didn’t cancel the patients I had waiting. I completed my current appointment, then took a few extra minutes to look at the schedule with my secretary to see where we could move the next day’s patients so I could drive to California in the morning. Then I went on with my day.

I still had three more patients left. Although none of them said anything, I’m sure they noticed I wasn’t mentally all there. I probably seemed distracted, checking my screen a few more times than I should have to see whether there were further updates. I don’t think I made any bad decisions about treatment, but I certainly wasn’t at the top of my game. A few days later, after things had settled down, I reread my notes from the day to make sure I hadn’t missed anything.

It’s a surprising reminder of how powerful the older, nonrational parts of our brains are. Although they didn’t take over, they certainly affected my ability to focus on the task at hand. There’s a reason those areas exist, too, even if we keep them hidden in our daily lives.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I recently picked up my daughter from summer camp, and on the 5-hour drive home she kept texting people back and forth. I asked her if they were other campers or counselors she’d befriended.

cyano66/Thinkstock

She said yes, they were other campers she’d met, but was horrified that I thought some might be counselors. Counselors, understandably, aren’t allowed to have any contact with kids outside of camp. Not by text, Instagram, Facebook, or any other modern social contrivances.

That probably should have occurred to me before I even asked. It makes sense.

I keep a similar policy with patients.

Nothing against them: The majority are decent people, and there are a few I could easily see being social friends with – meeting for dinner, going to a basketball game ... but I won’t.

Like the kids and counselors at camp, I need to keep a distance between myself and patients. I don’t have any social media accounts, anyway, but I keep the relationship confined to my office.

Keeping an emotional distance with patients makes it easier to do this job. While we may genuinely care about them and are trying to help, it’s important to be objective. Seeing them through the lens of friendship might affect the decision-making process.

The divider of professionalism is there for a good reason, across many fields. It allows us to try and think clearly, to give good and bad news, and make diagnostic and treatment decisions as rationally as possible, based on scientific evidence and each individual’s circumstances.

It’s what makes good medicine possible. I wouldn’t want it to be any other way.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I recently picked up my daughter from summer camp, and on the 5-hour drive home she kept texting people back and forth. I asked her if they were other campers or counselors she’d befriended.

cyano66/Thinkstock

She said yes, they were other campers she’d met, but was horrified that I thought some might be counselors. Counselors, understandably, aren’t allowed to have any contact with kids outside of camp. Not by text, Instagram, Facebook, or any other modern social contrivances.

That probably should have occurred to me before I even asked. It makes sense.

I keep a similar policy with patients.

Nothing against them: The majority are decent people, and there are a few I could easily see being social friends with – meeting for dinner, going to a basketball game ... but I won’t.

Like the kids and counselors at camp, I need to keep a distance between myself and patients. I don’t have any social media accounts, anyway, but I keep the relationship confined to my office.

Keeping an emotional distance with patients makes it easier to do this job. While we may genuinely care about them and are trying to help, it’s important to be objective. Seeing them through the lens of friendship might affect the decision-making process.

The divider of professionalism is there for a good reason, across many fields. It allows us to try and think clearly, to give good and bad news, and make diagnostic and treatment decisions as rationally as possible, based on scientific evidence and each individual’s circumstances.

It’s what makes good medicine possible. I wouldn’t want it to be any other way.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I recently picked up my daughter from summer camp, and on the 5-hour drive home she kept texting people back and forth. I asked her if they were other campers or counselors she’d befriended.

cyano66/Thinkstock

She said yes, they were other campers she’d met, but was horrified that I thought some might be counselors. Counselors, understandably, aren’t allowed to have any contact with kids outside of camp. Not by text, Instagram, Facebook, or any other modern social contrivances.

That probably should have occurred to me before I even asked. It makes sense.

I keep a similar policy with patients.

Nothing against them: The majority are decent people, and there are a few I could easily see being social friends with – meeting for dinner, going to a basketball game ... but I won’t.

Like the kids and counselors at camp, I need to keep a distance between myself and patients. I don’t have any social media accounts, anyway, but I keep the relationship confined to my office.

Keeping an emotional distance with patients makes it easier to do this job. While we may genuinely care about them and are trying to help, it’s important to be objective. Seeing them through the lens of friendship might affect the decision-making process.

The divider of professionalism is there for a good reason, across many fields. It allows us to try and think clearly, to give good and bad news, and make diagnostic and treatment decisions as rationally as possible, based on scientific evidence and each individual’s circumstances.

It’s what makes good medicine possible. I wouldn’t want it to be any other way.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.