How often do you see your doctor?  Once a year?  Every 6 months?  Never?  Most of you are pretty healthy and only show up for screening physical exams or aches and pains.  Some of you may have more health problems and come more frequently.

What if you had diabetes, coronary disease, hypertension, high cholesterol, and sleep apnea, but no symptoms to indicate any acute problems?  You’d probably see your primary doctor fairly routinely (mostly for management of diabetes) and maybe your cardiologist every six months or so.

Here’s my question.  When you’re coasting along pretty well with no actively changing symptoms but with chronic medical problems, how often do you need to see your doctors?  Let’s take the example above: with those particular problems, should you see your cardiologist yearly, biannually, quarterly, monthly, or what?  In the non-hypothetical world a patient’s follow-up is likely to be dictated by the doctor and set at the end of each appointment.  “Okay, Mrs. X, it looks like you’re doing well.  Let’s plan to see you again in 6 months.”

How does the doctor know when to see you next?  As a patient you probably don’t put much thought to this and obediently comply with whatever scheduling recommendation you’re given.  But ask yourself next time you see your doctor “how does he/she know when to have me come back?”  Is there some textbook somewhere, some set of guidelines that tells us how often patients with particular medical problems need routine follow-up?

The answer: Nope.

There are a few ground rules to take into consideration.  The pharmacy overlords don’t allow us to write prescriptions with refills that extend past 12 months, and many clinics have a policy of not providing new prescriptions after the 12-month mark unless they’ve at least laid eyes on the patient (apparently to make sure the patient is indeed alive), and so most people with chronic problems will likely have to be seen at least once a year.  The other ground rule is common sense.  If, as your doctor, I really wanted to gauge you and your insurance company for money I’d have you come back every week or every day.  That is obviously a silly care plan and you’d reject it immediately.

So, routine follow-up will most likely fall somewhere between “less often than weekly” and “at least once yearly or more frequently.”  But within those limits, as a doctor I’m pretty much free to choose whatever I like.

I don’t know how other doctors do it, but I like to burden healthy-ish patients with as few doctor visits as possible, so I mostly try to set my return appointments for a year.  This works well for most people, but there are clearly exceptions.  Some patients, most commonly ones I’ve inherited from other doctors, are so used to being seen biannually (or is it semiannually, or biennially?—I can never keep those straight) that I can’t even talk them into going an entire 12 months between visits: “Oh no, that’s just too long!  What if something happens?”  Others give me the exactly opposite reaction: “Really?  A year?  That’s great!  I must be getting better!” and they cheer as if I’m graduating them from a 12-step program.  As I wrap up my visit and suggest a return date there’s no way for me to predict who will be grateful and who will be fearful with a longer span between visits.

The most interesting misunderstanding I had in this regard was with a relatively healthy older patient whom I asked to return in 6 months.  When his appointment rolled around again he was accompanied by several family members who were all visibly nervous.  Once I dug into things a little I discovered that he had become confused by my follow-up recommendation and was led to believe that I was giving him only 6 months to live.  The poor guy had spent the last half year believing he was destined to soon transition to that great medical clinic in the sky, and the rest of his family had come along to hear my next pronouncement of his estimated longevity.

I commonly ask certain patients to see me more frequently.  Anyone in whom I make medication changes I’ll likely have back sooner to assess effect or any problems.  Patients with congestive heart failure (CHF) will generally come in every 6 months or sooner even if they feel great.  I recall sitting in a conference of fellow cardiologists when the issue of CHF patients and their follow-up was raised.  One attendee remarked that it was “common knowledge” that all patients with CHF should go no longer than 3 months between visits.  I don’t know exactly where that common knowledge came from—maybe there is a textbook out there and I just don’t know about it.

Symptom-free patients with chronic heart disease frequently give me a quizzical look when I walk into the exam room.  I’ll ask how they’re feeling.  “Great.  I don’t even know why I’m here.”  I try to tease out a little more—shortness of breath? chest pain? swelling in the legs?—but, no, they really do feel great and wonder why I keep asking them to come in even though they feel so good that they sometimes forgot they have heart problems.  I try to explain that I need to check on things they can’t feel, like blood pressure, heart rate, blood creatinine and cholesterol, etc.  They nod and give me the whatever look.  I offer them another chance to dig up any questions they have and I’m met with utter silence (cue the sound of a clock ticking, or coyotes howling softly in the distance).  So, I wish them well, remind them they can come in anytime if things change, and set up another visit in 12 months.  “Sure.  Whatever.”

Sadly, I’ve known doctors who use the unquestioning obedience of some patients to their own financial advantage.  Does a stable patient really need to come in for visits every two months or need a stress test and echocardiogram every six?  I don’t think so, but I guess I’m not the one trying to make payments on a new Porsche (is that still the cliché doctor’s car?).  I’ve taken on a few of those patients as well and they tend to be surprised and relieved to learn that I don’t think they need that kind of frequent testing or clinic visits.

Another area where I don’t have a clear answer relates to the need for a cardiologist at all.  A patient will come to me for help controlling blood pressure, or to treat benign palpitations, or for a pre-operative assessment.  Once I’ve made the medication changes that are needed and answered all the questions, does the patient need to keep coming back to see me?  I don’t know but probably not.  Primary doctors (family practitioners and internists) are fully capable of treating hypertension, palpitations, and the like.  In most cases I tell the patient they don’t necessarily need to see a cardiologist on a regular basis but that I’d be happy to see them at any point in the future.  Many say they’d feel better with scheduled follow-up and for them I’m happy to oblige.

So, in summary: How often should you be seeing your doctor?  I have no clue.  Between you and your doctor you’ll come up with some type of balance that works.  Just understand that none of this is written in stone.  Or in some textbook. 

Unless it really is and I just don’t know about it.

We just added two new cardiologists to our practice.  Drs. Ann Narmi and Ruby Satpathy recently completed their cardiology training and made the decision to become members of the Alegent Heart and Vascular Specialists (either that or it was part of their parole negotiations—that’s how I ended up here).  If you were to review their curricula vitae you would come to two conclusions:

1. Both are highly qualified, impeccably educated and eminently talented cardiologists.
   
   
2. Both are women.

I highlight the latter point mainly because the addition of two women to our group, along with the two we already have, gives us far more X chromosomes than you'd find in almost any other cardiology practice.  As I’ve pointed out in a previous blog post, the field of cardiology (and in particular the subspecialty of interventional cardiology, in which both of our new doctors are trained) has traditionally been dominated by men.  Given the fact that more than half the medical students in our country are women we’re bound to see more and more female cardiologists in the future.

I really enjoy the diversity in my group and in the field of medicine in general.  Not only do we see more women in medicine but we are also fortunate to have doctors of various nationalities and backgrounds.  When I first came to Omaha I was part of a group that included doctors from nearly all seven continents (despite our best efforts we failed to recruit anyone from the Antarctica School of Medicine) and group meetings felt a little like diplomatic gatherings at the United Nations.

As a patient I don’t think I’d care what gender, nationality, religion, color, texture or flavor my doctor is—the metrics I’d employ would have more to do with competency and communication.  I wrote about this topic in another blog post last year:

Here’s my list of what I think patients value most in doctors:

1. Bedside manner, interpersonal relationship, and communication skills.  According to a survey from the United Kingdom cited on WebMD http://www.webmd.com/news/20080310/what-do-patients-want-from-doctors the most sought-after physician attributes are a “warm, friendly manner” and “a doctor who knows me well.”

2. Accessibility.  The same study cited “short waiting time” and “flexibility in selecting appointment times.”

3. Clinical competence.

Somewhere down the list falls “a diploma on the wall with an Ivy League school emblem,” probably right below “ruggedly handsome good looks” and just above “pleasant waiting room feng shui.”

I guess the list I made last year failed to take one particular thing into account: birthplace.

An interesting article was printed last week in the New York Times called “When The Doctor Doesn’t Look Like You” that addressed the issue of doctors who hail from foreign countries (currently, roughly one-quarter of all practicing physicians).  The story highlighted the bias some patients have against doctors whose skin color and accents are not typical of the local community.  I have seen this on many occasions.  I know of patients who request that they see only doctors who are from the US and other patients who have switched from doctors simply because they speak with accents that are un-Nebraskan.

The bias, by the way, relating to doctors and their provenance extends also to other factors.  Just last month I had a patient choose me as his doctor simply because I come from Utah.  He had spent many years there and wanted someone he could relate to.  I’ve had patients who refuse to see female doctors and those who want to see only female doctors.  A patient I saw last week was sent by one of our Alegent Health Clinic doctors whom he had only recently met.  I mentioned that I hadn’t met his new doctor but that I’d heard that she is quite good.  His response: “I don’t know but she’s really hot.”  (Contrary to what you might think I didn’t immediately go look her picture up on the Alegent website.  Not immediately.)

The most common bias I have encountered relates to physicians from other countries, the so-called foreign medical graduates.  I've put some thought into this bias and have concluded that there are four possible reasons a patient may object to having a foreign doctor serve as their caregiver:

1. Patients may not feel comfortable with a doctor who they perceive may have different cultural background or values than they have.  They may believe that a physician born and trained in Nebraska is far more likely to be able to relate to the problems Mid-westerners face than someone born in South America or India.
2. While all foreign medical graduates speak English they may still have accents that make it hard for some people—particularly older patients with hearing difficulties—to understand.
3. Patients may have the perception that foreign doctors are not as well trained or as capable as their domestic counterparts.
4. Finally, ethnocentricity and racism may play a role.

I sincerely hope that point number 4 constitutes only a negligible portion of this bias but I can't tell.  I've heard patients casually relate extremely discriminatory remarks to me as they describe doctors or nurses, obviously believing that I hold the same view.  Still, I have to think that the cultural and language elements (points number 1 and 2 above) are the biggest culprits among patients who don't feel comfortable with foreign doctors.

Point number 3—the assumption that doctors from outside our borders are poorly trained—can be easily debunked with empirical evidence.  In a study published this year in Health Affairs, researchers combed the records of 244,000 patients admitted to hospitals in the United States who came under the care of primary physicians.  The authors correlated the outcomes of these patients with the nationality of their doctors.  The verdict?  Doctors from other countries outperformed locally grown MDs when it came to patient survival and complications.  The authors attempted an explanation for this discrepancy in a commentary published in the Times:

“John J. Norcini, lead author of the study and president of the foundation, postulates that the differences may stem from the fact that as primary care has become less attractive for graduates of American medical schools, it has also become less competitive. ‘The foreign international medical graduates are some of the smartest kids from around the world,’ he said. ‘When they come over, they tend to fill in where the U.S. medical school graduates don’t necessarily go.’ ”

I can tell you that we are very fortunate to have extremely high-quality doctors in Omaha (who, at one point, must have also been some of the smartest kids around) and many of them are foreign medical graduates.  We have doctors of all nationalities, backgrounds, languages, genders, religious persuasions—even former Utahns—and their competency lies in their training, intelligence and dedication and not birthplace or skin color.

We now live in an age where our Surgeon General is an African-American woman, where the most trusted medical voice on television is Dr. Sanjay Gupta (of Indian descent), and where fewer and fewer doctors look like Marcus Welby, M.D. or Dr. Kildare.  In my group we have two cardiologists who hail from countries outside the U.S. and who happen to be two of the most talented and capable cardiologists I've met.  In an increasingly flat world it is clear that patients will serve themselves best by judging their caregivers on merit rather than by appearance.

I saw an article in the paper a couple weeks ago about how the medical school at Brown University had begun admitting a small number of students each year without requiring them to take the usual premedical science requirements or the Medical College Admission Test (MCAT, commonly pronounced either “em-cat” or “night-mare”).  This comes as quite a revelation to me but not really much of a surprise.

To get a feel for the world of the premedical student all you have to do is spend an evening in the science section at the library of your nearest 4-year university.  There you’ll find a horde of students pouring over their microbiology and physics textbooks, fretting over the next organic chemistry test, and plotting ways to talk their professor into switching their latest B+ to an A-.  They’re the ones who will toss their classmates under the bus if it means they end up with a slighter higher standing in their zoology class.

There’s actually no such thing as a pre-med major (contrary to what many college freshmen may claim in a futile effort to enhance their social life), just a pile of courses that all medical schools require of each student hoping to become a doctor.  Everyone who ends up going to medical school has graduated in some subject and most stick to the sciences: biology, zoology, biochemistry, physics, etc.  That makes sense: it’s easier to survive college and the pre-med requirements if your major already encompasses most of the 32-some-odd credits of necessary study.

A much smaller fraction of premedical students spend their college days outside the science buildings.  I found the environment of the premedical world rather suffocating, but for reasons other than being surrounded by the highly-competitive doctor-wannabes—I simply didn’t like biology and chemistry all that much.  Add to that the pressure of having a father who was a renowned anatomy professor at the same university I attended (all the instructors of the pre-med courses were members of his department and expected nothing short of brilliant perfection from his son) and it was enough to drive me straight to the humanities building.  I spent the last two years of my college days analyzing Goethe, Lessing, and Schiller in the German department and far from the pre-med pressure cooker.

My choice in major came back to haunt me the day I took the MCAT.  As it was administered in the eighties (it has since be reworked) it was a punishing 12-hour grind that was somewhat like waterboarding but with less day-spa ambience.  The test focused on every detail of physics, calculus, chemistry, and biology imaginable.  Curiously, the sadistic writers of the test seemed far less interested in the lyrical prose of Rilke or the novels of Heinrich Böll than in the lifecycle of the typical tapeworm, and thus I found myself at a distinct disadvantage to my fellow science-majoring students.  I recall walking out the testing center that day vowing that if my MCAT score proved inadequate I would rather abandon my aspiration of medical school than to ever submit to that test again.

Well, I don’t recall my score, but it must have been high enough to land me a few interviews.  Being from Utah I was very interested in attending the University of Utah in Salt Lake City and was assigned interviews with two senior medical professors.  The first, an anesthesiologist, zeroed in on my German major immediately and expressed concern about my apparent lack of a solid science background.  From there things went downhill and it became quickly apparent that a grade-schooler at a science fair looked more like his ideal of the perfect medical student than I did. 

My second interview was with an aging neurologist who also began by commenting on my choice of undergraduate study.  He asked me to defend my decision to major in a language rather than in biology like most everyone else.  By that point I knew I had no chance of spending my medical school years in Salt Lake and subsequently began to be less anxious.  Calmly, I replied that a humanities major allowed me to explore a broad spectrum of knowledge before I was consigned to 4 years of strict scientific study; that literature in particular enabled me to have a better understanding of human nature; and that the skills I’d learned in literary interpretation could prove to be useful in future communication with patients.

He smiled when I finished and to my surprise settled in to tell me his own story.  Years earlier he’d been the only member of his incoming medical class to have not graduated in a field of science and that his choice of Latin as a major had provoked considerable discussion among the members of the admissions committee.  Reluctantly they admitted him to the school but on the condition that he actually perform better than his classmates during the first year of basic science study.  Of course he succeeded and, years later, there he sat explaining to me why he thought I’d fit right in among the members of the matriculating class.

He was right, although for the first few weeks I felt like a fish out of water trying to catch up with my classmates who already had a solid grasp on histology and biochemistry.  People sometimes say that the first two years of medical school is a lot like trying to get a drink by putting your mouth on a fire hydrant—the volume of information is simply staggering—and I’ll admit I struggled to survive.  The last two years of medical school had us spending time in the hospital wards and clinics and it was in that environment that we began to figure who among us would become successful doctors.  One thing became quickly apparent: there isn’t much correlation between getting high scores in the basic sciences and succeeding in the clinical environment.  Sure, a solid understanding of anatomy, physiology, and pathology were indispensable and no student, no matter what kind of wonderful bedside rapport they may have had, succeeded without a stable foundation of medical knowledge.  My experience at the time—and this has been validated for me as I’ve progressed through my career—was that the best measure of a quality physician was not his or her scores on biochemistry tests.

Yet MCAT scores and grade point average in the basic sciences are the only objective parameters medical admissions committees have to filter the thousands of applicants that line up at their doorstep.  A student who could potentially become a great doctor won’t make it past first base if he or she can’t perform adequately in physics and chemistry, unless they apply to this year’s class at the prestigious Brown University, of course, where they might gain entrance without ever having to submit to the MCAT.  You may think that with my Bachelor of Arts (rather than Science) I would be solidly in favor of such an evolution but I confess that I have mixed feelings.

It is apparent to everyone in the medical establishment that we need doctors who can do more than just regurgitate scientific facts and formulas.  For years medical schools have been looking for ways to include in their applicant assessment a way to tease out the “humanism” in potential students.  The MCAT has been restructured to incorporate an essay section that requires students to ruminate on subjects more subjective than the Krebs citric acid cycle.  Most schools now put far greater emphasis on the interview process than on grade point average.  With studies showing medical school academic performance is similar for students with a humanities background (or arts, music, etc.) and those reared in the sciences, many schools actually try to recruit applicants who have a more varied resume.

What’s also needed, though, are students who can master the massive volumes of information needed to practice medicine in today’s technological age.  Recall the analogy of the fire hydrant and remember that the knowledge encompassed in the world of medicine doubles every few years; yet despite this medical school remains fixed at only 4 years—just like it’s been for 2 generations.  As far as I can tell, being able to succeed in the pre-med classes and pass the MCAT still seem to be the best indicators of those students who will be able to handle the academic rigors of medical training.  A great bedside manner will do you no good if you can’t get through your first year of medical school.

In the end I’m grateful that I majored in German rather than microbiology for all the reasons I spelled out in my medical school interview.  While being able to speak German hasn’t done me much good (unless you count being able to accurately pronounce words like Wenckebach and Trendelenburg), studying Goethe has.  I think medical schools are now reaching a better balance between the hard sciences of physics, math and chemistry and the soft sciences of communication, empathy, and creativity.

The New England Journal of Medicine just published a study casting doubt on the utility of rescue breathing—commonly known as mouth-to-mouth resuscitation—in cardiopulmonary resuscitation (CPR). Residents in the state of Washington participated in a large trial in which emergency dispatchers recommended either chest compressions accompanied by rescue breathing or chest compressions alone as they gave instructions to bystanders in the cases of 1941 people who suffered out-of-hospital cardiac arrest. The success (or, more accurately, lack of success, since only 1 in 8 patients survived to hospital discharge) of the victims was followed and tabulated. Persons receiving the full “standard” CPR that included mouth-to-mouth did no better (in fact, a little worse) than those who received only chest compressions. The verdict of the study is that the use of rescue breathing by bystanders is of no benefit.

This report comes on the heels of other studies that produced similar results. A paper published in 2006 evaluated a similar system of “CPR minus mouth-to-mouth” and showed that focusing on the “cardio” part of CPR and eliminating the “pulmonary” portion proved to be a vast improvement. Another study from Japan, published in The Lancet in 2007, demonstrated improved success of resuscitation if it were limited to chest compressions only.

The findings of these studies are actually not too surprising when you take into context the mechanism of cardiac arrest. In most cases of witnessed collapse in adults the culprit is a malignant ventricular arrhythmia such as ventricular tachycardia or fibrillation. In these instances the heart begins to beat so rapidly that it’s unable to effectively pump blood to the body and simply quivers in the chest as the patient loses consciousness and the brain becomes starved for oxygen. The only effective therapy is the delivery of an expeditious electrical shock to the chest by a quick-witted bystander or emergency medical team. The shock effectively “resets” the electrical status of all the cells in the heart, allowing the sinus node (the small island of tissue that serves as the usual pacing center of the heart) to regain control of the organ. The whole purpose of chest compressions is to forcibly and artificially provide a limited amount of circulation to the heart and brain until somebody shows up with a defibrillator—in doing CPR you’re simply buying a few minutes of time until EMS can get to the patient. Adding mouth-to-mouth resuscitation does nothing more than distract you from pumping on the chest.

Worse, the prospect of placing your mouth over the mouth of a collapsed stranger can also deter you from jumping in as a volunteer in the first place. I’ve never personally been in this situation, but my wife has. Shortly after we were first married and the Air Force banished me to a dusty border town in Texas to serve 2 years as an internist, my wife (an ICU and ER nurse) took an extra job with a home health agency to help pay the bills. On her very first day she walked into the home of an elderly female only to see the patient clutch her chest and collapse. My wife called 911 and rushed to begin CPR only to find the patient’s mouth covered in a cocktail of half-chewed breakfast burrito, free-floating dentures, and vomit. Dutifully, my saint of a wife plunged in with chest compressions and the “kiss of life.” Needless to say my next birthday present for her was a CPR pocket mask that she could keep in her car (widely available at a reasonable price) and a promise that I’d someday find a job that pays more than minimum wage.

The concept of bystander CPR has been around for about 50 years now and was made popular by numerous books and training videos after researchers stumbled upon the concept of “closed chest massage” (previously, hospitalized victims of cardiac arrest were eviscerated by resident surgeons attempting open heart massage—the only type of resuscitation known at the time). The addition of rescue breathing was based on the theory that artificial ventilation was a necessary adjunct to the resuscitation effort, a supposition that was never clinically vetted. Over the years it has been canonized by generations of Basic Life Support instructors and is now embedded into our culture much like the Heimlich maneuver, “starving a cold and feeding a fever” (or is it the other way around?), and the mantra to not run with scissors.

Soon that will all come to an end. Just two years ago the American Heart Association released a consensus statement calling for an end to mandatory mouth-to-mouth resuscitation in adult arrest victims unless they succumb to drowning or drug overdose (children, by the way, are far more likely to suffer from respiratory compromise and should always be treated with both chest compression and rescue breathing). It’s likely that the International Liaison Committee on Resuscitation will soon revise their guidelines to reflect these recommendations.

The real tragedy in this whole turn of events has nothing to do with 50 years of futile mouth-to-mouth by thousands of well-meaning strangers who stoically pinched the nose of downed victims and dove in for an intimate but ultimately fruitless exercise in lip-to-lip bonding. No, the real victim here is Hollywood. For as long as I can remember, CPR (along with amnesia, that other equally abused medical condition) has been a favorite tripe of screenwriters looking to exploit the dramatic or comedic effect of two strangers intertwined in an intimate struggle for life.

Just take a moment and think about all the times CPR has played a central role in movies you’ve seen. The leading lady has suffered some sort of traumatic injury to the chest (gunshot, drowning, stabbing) and the hero comes to the rescue with a gallant display of lifesaving resuscitation, chest pounding, and lots of dramatic proclamations: “live, damn you!” or “don’t you dare die on me!” The all-time greatest CPR scene (or worst, depending on your perspective) is found in the deep-sea sci-fi flick “The Abyss,” where the female lead drowns at the bottom of the ocean and is pulled—blue, lifeless, nearly barnacled—into the undersea research complex by Ed Harris, her heroic counterpart. Standard resuscitation ensues with a mix of ineffective chest compressions, electrical shocks and worried, teary faces. After several minutes the team admits defeat and terminates their efforts. That’s when Ed Harris’ character flies into a life-saving frenzy, swearing and cursing and slapping her rigor mortis body back to health as he jettisons the oxygen mask in favor of the more intimate mouth-to-mouth. As with all Hollywood drowning victims she dutifully spits out a little water and is ready for her next scene.

Where would the movies be without the comedic device of rescue breathing? Think back to “The Sandlot,” the 1993 coming-of-age film where the tweener runt of the group fakes a drowning in the community pool to score a little lip action with the voluptuous life guard. Or consider the movie “Superman” (the first with Christopher Reeve) where the evil mastermind Lex Luther distracts an army battalion by enticing their commander (played by Larry Hagman) to gleefully perform mouth-to-mouth on the well-endowed Miss Teschmacher:

Sergeant Hayley: She's having trouble breathing sir. What do you think?
Major: Well, I suggest a vigorous chest massage, and if that doesn't work, uh, mouth-to-mouth.
Sergeant Hayley: [enthusiastically] Yes, sir! [bends to the task]
Major: [the Major pulls him to his feet] Sergeant, I won't have one of my men doing anything I wouldn't be prepared to do myself.
Sergeant Hayley: [disappointed] Yeah, but, sir!
Major: Get an ambulance. All right, men. Gather around. About face!

If and when rescue breathing becomes a thing of the past, where does that leave all the screenwriters in need of a sure-fire gag? I suppose they still have the rest of CPR to draw from. After all, there’s still plenty of drama in chest compressions and defibrillation (that alone was the central plot line of the 1990 movie “Flatliners”).

Not that Hollywood’s depiction of CPR is in any way helpful, mind you. It’s likely that the public’s overly optimistic belief in the success of cardiac resuscitation stems from being inundated with movies and TV episodes where seemingly dead victims spring back to life after a few chest compressions. A few years ago the New England Journal of Medicine published a study comparing the success of CPR in the real world to the fictionalized version on TV. Not surprisingly, victims of cardiac arrest on shows like “ER” faired much better than we see in the community (75% of fictional patients enjoyed immediate recovery, while the actual rate meaningful survival is typically well below 30%). The authors of the study maintain this discrepancy is harmful and leads to unrealistic expectations:

“In a subtle way, the misrepresentation of CPR on television shows undermines trust in data and fosters trust in miracles. . . . We should clarify misperceptions, provide actual data on outcomes, and address specifically the differences between CPR as seen on television and CPR as it is experienced by real patients.”

This newest article that casts doubt on the utility of mouth-to-mouth is a breath of fresh air into a subject that is steeped in history, misinformation, and pop culture. Hopefully there will soon be new guidelines that reflect this information and improve the application of CPR in the community. At that point the only group to suffer from this will be the Hollywood screenwriters; but, to paraphrase Humphrey Bogart, we’ll always have amnesia.

Have you ever wondered what your doctor is writing as he or she is busy scratching away in your chart?  What strikes him as being important?  What does she ignore?  Or is he just drawing cartoons in the margins? (For the benefit of those readers who are actually my patients I can honestly confess that I’ve never doodled cartoons in your chart as I listen to you—my cartooning skills are simply too inadequate.)  If you were to read my hand-written notes they would go something like this: Srmfth kllmquis is hmmelsh fluthyig percquler hablehc.  My writing is no better than another doctor’s, since we all took the same “Illegible Handwriting 101” course our first year of medical school.

What’s more revealing is the final dictation that ends up in your doctor’s record.  Once she’s done visiting with you she takes to the computer keyboard (in the case of the computerized medical record) or to the Dictaphone to produce a more legible and lucid summary of your visit.  It includes the stuff you told her, her exam findings, and her impression of your medical problems.  It concludes with whatever recommendations she made to get you feeling better.  It basically summarizes her version of the interaction you two just had.

How’d you like to get a hold of that report?

Well, you may not realize this, but you’ve been able to for some time now.  Ever since Congress passed the Health Insurance Portability and Accountibility Act (HIPAA) of 1996 you’ve had legal write to not only cast eyes on your medical record but to also make amendments as you see fit.  Give it a try sometime.  March into your doctor’s office and ask to take a glance at your folder (or electronic file, as the case may be).  Odds are pretty good the clerks at the front desk will give you a funny look, but rest assured they are legally obligated to turn the whole stack of papers (or electrons) over to you.  Some offices will charge you a “processing” or “copying” fee, others will allow you to see your record only under the watchful eye of a clinic employee, and some may simply deny you access, not being familiar with a legislative change that went into effect 14 years ago.  Still, the law is on your side and you have every right to exercise your privilege.

Let’s pretend that after reading this post you decide to drive down to your doctor’s office and ask to see her most recent dictation about you.  As you stand there at the front desk and ask for your chart what do you imagine is going through the mind of the receptionist?  This patient is going to sue us.  Or, this patient is obsessive-compulsive.  Or, this patient is going to switch to another doctor.  I seriously doubt they would be thinking this patient has a rational concern about his own body, would like to be a better partner in his own healthcare, and is improving the process by educating himself. 

Nope—they’re thinking you’re nuts.

The funny thing about all this is that it rarely happens.  I can’t say for sure how many of my patients have requested access to my notes about them but I’d guess that less than 5% of them ever get the urge to check out their charts. 

Or, maybe they do, but they’re just afraid to ask.

The most recent issue of Annals of Internal Medicine contained a paper outlining the OpenNotes project:

“ ‘a demonstration and evaluation project in Massachusetts, Pennsylvania, and Washington, in which more than 100 primary care physicians are inviting their patients to read their visit notes through secure electronic patient portals.’  These clinics are taking a step beyond simply allowing their patients open access to their records upon request—they’re suggesting their patients sign in to a secure site to see every detail of their file at a moment’s notice.”

I actually really like this idea.  Maybe the reason so few people ask to look at my notes is that they’re afraid they’ll be branded as problem patients.  The OpenNotes project solves this problem by allowing patients to search their record in the comfort of their own Starbucks store without having to interact with a snoopy medical records clerk or suspicious nurse.  As a doctor, I’d never know which of my patients has dug into my most recent ramblings about them.

Several large news outlets wrote stories about this publication, including the New York Times, in which the author—a physician—expressed similar notions as my own as she described a scene where an elderly couple requested access to their charts:

When I mentioned the request to one of the nurses outside the exam room a few minutes later, her eyes grew wide.

“Oh no, you can’t do that,” she said, shaking her head. “I don’t think it’s legal.” The other doctors and nurses, attention piqued, moved closer to listen. “Send them to medical records,” she urged. “He can sign the release papers there.”

Another nurse in the growing crowd offered her own advice. “Do you know what’s going to happen if you give them a copy now?” she asked. “They’re going to start calling and e-mailing you with questions about what you wrote.”

The doctors and nurses began clucking in agreement. “Think about it for a second, Pauline,” one doctor said with voice lowered. “Maybe they are thinking of suing you.”

There was a collective gasp from the group now gathered around me; and I could guess what they were thinking as they craned their necks to peer into the exam room where my elderly patient was busy fussing with his papers as his wife stood adjusting the canvas fishing hat on his head.

The article, and the numerous reader comments on the website, went on to speculate about the other hazards of allowing patients to rifle through their record.  What happens when a patient comes across confusing terminology or encounters some of our cryptic abbreviations and acronyms?  The phrase “This 42-year-old well-developed female with SOB” could be misinterpreted as derogatory commentary on the patient’s physique and choice in husband, rather than the intended meaning (well-developed means not malnourished, and SOB is generally translated as shortness of breath; although I have met some unfriendly spouses for whom the phrase could serve as a double entendre).

What happens when they read the part of my note where I speculate what other diagnostic possibilities might account for their symptoms?  While the patient’s SOB is most probably caused by his known emphysema, less likely possibilities could include coronary ischemia, congestive heart failure and occult malignancy.  Most people would recognize that I’m simply speculating (or, rather, doing what I was taught in medical school: developing the differential diagnosis) but some might infer that I have secret knowledge about their impending doom that I’m withholding from them.

And when they come across slight abnormalities in their testing—abnormalities that I gloss over during my visit with them—will they suspect me of indifference or poor judgment?  If I don’t explain my theories as to why their AST (a blood test reflecting function of the liver) is a point higher than the norm, will they inundate my office with phone calls and demand additional testing?

Well, these are the fears that have been expressed by doctors, nurses and some patients.  Personally, I don’t think any of them hold water.  The way I see it, these objections are nothing more than a diversion from the real concern of the medical establishment: we are afraid of giving up control. 

Ever since Hippocrates scribbled illegible medical notes (and, perhaps, little cartoon doodles) onto parchment we’ve had complete control over the documents that record the interaction we have with patients.  We’ve invested so much into our system of medical record keeping that we’ve come to believe that it belongs to us rather than the patient.  And on some level we’re still suffering from the paternalistic views of our professional forbears: the best patient is an uneducated and subservient one.

Sure, there may be some who will become confused as they read through the technical lingo of our profession, and there may be others who become fearful when they peruse the cold and relatively impersonal recounting of their health problems, but my guess is that most patients will appreciate the additional information that comes from being able to lay eyes on their record.  Those patients may also want to exert more control over how their care is provided and we may find that they become more like partners in the process rather than passive customers, a proposition that I have no objection to.

Proponents of the open access movement claim that patients who have access to a summary of their office visit will be more likely to adhere to their doctor’s suggestions, can help improve the accuracy of the record, and will ultimately develop more trust in their physician (a nice table summarizing the pros and cons of OpenNote is available here).  I’m not sure how my patients would respond to such an opportunity.  A few years ago when I was in the military we had an electronic medical note system that allowed me to immediately print a copy of the report for my patients as they left my office.  Most were politely grateful, some were indifferent, and only rarely did I get any feedback or questions about what I’d written.

Will open access be a disaster (as some people fear) or a blessing (as others hope)?  I don’t have a clue.  As for all my patients, please feel free to come take some time reading through my notes about you.  Because, to be honest, the only concern I have is not that you’ll become confused or enraged or frightened by what I’ve written about you, but that you’ll be struck with a profound and potentially dangerous attack of boredom: my notes are not really all that fascinating.  While I may wax verbose in my blog posts, my office dictations are dry, concise, and include no commentary from me about your choice in husband.

And they don’t even include cartoons.