December 2017

Is there a future for robot-assisted surgery?

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Recently, there was a fascinating article in the Wall Street Journal regarding robot-assisted surgery. It reported the results of two articles published in JAMA that demonstrated that robotic-assisted surgery cost more and took longer without achieving superior results to laparoscopic surgery on average.

With this, my LinkedIn account lit up. Here are several of the comments that came through:

“I’ve come to assume that robotic surgery is better for GYN and colon surgeries simply because of their increased precision and accessibility to small spaces.”

“Robots are sexy, the media covers it like it’s the next best thing since sliced bread, and advantages may or may not be earth-shattering. Since when has that ever stopped a sale?”

“If you’re a surgeon: would you rather stand uncomfortably over a patient for 2-3 hours, trying to manage laparoscopic instruments? Or would you rather sit comfortably at a console and feel like you’re playing a surgery video game? It isn’t about outcomes. Plus, robots are cool to patients.”

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This physician is burned out. But not for the reason you think.

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I am an Olympian. I am a retired All-American student-athlete.  I am a resident.  I am burned out.

Let me be clear: I love medicine and the opportunity to have privileged relationships with patients and their families.  I thrive on the fast-paced environment, growing to-do lists, and the chance to work in a field with endless learning.  I love working in team environments to provide optimal care for patients and their families.  The most rewarding point in residency training has been the transition to a senior resident where I can create positive learning environments for other learners.  Practicing medicine is an extremely fulfilling career that I am very fortunate to have pursued, and I will never regret that choice.

The demands of patient care and the number of hours residents work is not the primary reason for my burnout.

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5 expenses that go down after you retire

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In order to safely plan for a successful retirement, it’s imperative to have a general idea of what your spending needs will be when retired. We cannot calculate whether or not our anticipated withdrawal rate would be considered safe (in the range of 3% to 4%) without knowing the size of the annual withdrawal.

That number can be difficult to pin down, as there are many variables. It can be informative to budget (we don’t) or track spending (we do), but this year’s spending might not look like last year’s, and could be entirely different than what we will end up spending in retirement.

Fortunately, there are a number of categories in which your annual expenses can be expected to drop when you give up the day (and sometimes night) job.

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Medical workers: Vaccinate yourselves first

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Just under half of health care workers do not get their annual flu vaccine. Some of these workers contract the flu and unknowingly transfer it to their sick hospitalized patients, and in some cases, because of them passing the flu along, those patients die.   We know the most important reason for health care workers to get vaccinated against influenza is that it is the most effective way of preventing influenza among their patients. And yet, unfortunately, many health care workers are putting patients at unnecessary risk.

If medical professionals know this, then why aren’t they complying?  As physicians, one of the most challenging things we do is to encourage our patients to comply with our treatments.  Why, then, do we not comply with a preventive treatment we know we protect our patients and ourselves?  I asked colleagues about this over the years and they have usually told me that they are either afraid of side effects or they don’t believe that the vaccine works.

There is more than enough data to prove them wrong.

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Insurance and the destruction of our health care system

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When interviewing for my book, I asked about insurance, but the topic came up even when I didn’t specifically ask about it. It was never positive in relation to practice.

A doctor said, “I expected to be around tough and hard cases. I expected it to be hard. I did not expect to have to think if the insurance company will not pay for it.”Another one said, “This completely changes the role we play as physicians The insurance companies are taking the ability to practice medicine the way we want to away from us.” Another doctor agreed, “It used to be in the days of yore you provide the services you thought were appropriate. Now there are restraints via insurance companies willing to pay what they are entitled to and what we can offer.” Another one agreed, “You have to watch the bottom line, or you get kicked off of the insurance panels and the hospitals and cannot earn a living. It is not most important to take care of people.” Overall, said one, “The insurance companies did not have as much power dictating things to me in the past as they do now.” One doctor said, “Insurance companies weren’t allowed to deem a recommended procedure as unnecessary not indicated and not reimbursable.”

The patients get hurt. “Patients don’t get adequate care sometimes.” and “They get inferior care,” said two interviewees. “Now almost anything we do we have to really think about the cost-benefit ratio to the patients. Will the insurance company pay? If not, can the patient afford it? Will the patient be physically harmed if they don’t get it? How can I help this patient?”   Another said, “We see more patients skipping their appointments and meds.” Shockingly, “There are delays in diagnosis. Delays in treatment. And in some cases, I had to cancel surgery because of insurance reasons.” In summary, “We are not delivering as good a product as we think we are. It comes down to insurance companies having too much power over the processes.”

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Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.


The hidden work of primary care

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It was nearing the end of my day at the mobile health clinic where I work as a nurse practitioner, providing free, comprehensive primary care to uninsured patients in central Florida. Clinic was officially over, and we were no longer taking patients; I was signing notes and finishing up some teaching points with a PA student when a woman walked up and asked me if she could “talk to me for a minute, just to ask a quick question.” After many years working in community health, I know these types of requests are rarely “quick,” but, understanding our patients’ limited opportunities access to care, I obliged.

As soon as we walked into a private space, the woman, whom I’ll call Alice, began to unload.

“I’m having all this belly pain. I think it’s from my cervical cancer which has spread to my ovaries. I went to the ER, and the doctors didn’t do anything. They did a pap smear, and I think they’re hiding my cancer from me.” This stream-of-consciousness deluge went on for several minutes while I listened and nodded despite my growing anxiety at having gotten myself in over my head with this unplanned clinical visit.

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The demand for preparation: from the playing field to the OR

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We often pull comparisons between unexpected resources in any given profession, especially when it comes to adopting tried and true best practices. For example, I always encourage hospital systems and training institutions to look to the hospitality industry for the treatment of patients and guests, among other areas. Last year, as I settled into my seat on a cross-country flight, I witnessed a textbook example of looking outside the box for surgical training inspiration.

One aisle over from me, an NFL coach taped pages upon pages of plays across the seat in front of him, studying for an upcoming game. As a practicing head and neck surgeon and an advocate for constant education, I imagined how great our healthcare system would be if we all prepared for surgery with the matched fervor of this coach.

Before diving into the details of what surgeons can learn from football, there’s one other important story to tell. Recently, I was in the backseat of an Uber when the driver asked how long it took me to become a doctor. Anyone who is currently practicing knows this is not an easy question to address. My answer was two-fold.  First, it took me eight years of schooling, but truly 14 years before I was able to become a surgeon. It takes several years to be fully prepared to take care of patients. Physicians go through a tremendous amount of training, so we certainly can’t say that any one person (football coach vs. surgeon) is more prepared than the other. However, it’s possible for a mindset to creep in once you’ve been practicing for a significant amount of time — the mindset that it’s acceptable to continue what you’ve been doing since day one. So, how do we remedy this? We use the coach on the plane as an example.

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Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.


It’s important to give patients an idea of what to expect

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The familiarity that health care professionals develop with complex medical procedures and topics is the result of years upon years of hard work, and over time we become accustomed to the jargon. We use phrases like “lap chole” and “appy” without much thought when talking to each other and (if we have a momentary lapse) with patients. We take the fantastic array of medical specialties, procedures, and knowledge in our world for granted. The extraordinary becomes mundane.

For patients, medicine is very different. The situations they encounter are, for the most part, totally novel. They don’t go through two gallbladder removals or appendectomies. They often walk into our offices without a clear picture of what will happen. The experiences that patients have can be overwhelming, bizarre, and frightening.

That’s why, when we refer patients to others or put them through a new experience, it’s so important to help give patients an idea of what to expect. Not just the broad-level overview, but specific, concrete details. It’s critical to make sure a patient understands what test or treatment they need and why, and informed consent is the bedrock of modern medicine. But it’s also valuable to give patients a touchstone about what the experience will look and feel like for them.

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So you want to make a big purchase. How do you save for it?

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Most people’s monthly spending is a series of recurring payments, like rent, food, and utilities. There are also some one-time purchases that might require a few months of saving, like a nice vacation or a new suit.

And then there are some things that require many months or years of savings.

An engagement ring. A wedding. A new car. A down payment on a house.

When saving for big purchases, how do you go about saving the money, and how should you invest those savings before you buy?

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Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.


Many digital health solutions lack evidence: How physicians can help

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Technology makes this an exciting time for health care. Not only are technological advances making health care better, they’re also making it more affordable. To get a taste of the potential of where health and technology are going, you only need to look as far the recent Fortune article titled, “Prepare for a Digital Health Revolution,” or to search through the more than 300,000 health apps available today.

But is all this excitement just hype? Opinions differ. Last year the CEO of the American Medical Association (AMA), the nation’s largest association of physicians, described many of the current digital tools as “the digital snake oil of the early 21st century.” That bold statement is certainly founded in some amount of reality, since many of the tools currently available have not been validated by clinical studies. And for risky medical products, such as implantable devices, testing is critical. But there are other health tech products, such as mobile-based education programs, that carry far less risk—and may not need the same rigorous clinical study standards before hitting the market. Yet, in all things, the lines between risky and safe products are blurry. And even in products that pose low levels of risk, the medical community should look for proof of efficacy and cost-effectiveness before adopting and recommending a digital tool.

On the surface, the answer seems simple: every medical tool should be required demonstrate efficacy through large, robust clinical studies. Unfortunately, however, that might not always be a viable option. For many small startups, every dollar has to be spent wisely. Time is literally money. For a young company, having a study delayed for weeks or months could be the difference between success and failure—regardless of how the product actually performs. That may be why many companies don’t perform outcome studies—they are under pressure to move fast and generate sales, so teams determine that there isn’t enough time to show outcomes. Starting a business is tough. Many fail. In fact, recent statistics show only 3 percent of startups make it to year five. And in the tough technology startup field, even well-intentioned companies may have to make tough tradeoffs to stay afloat.

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Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.