If you don’t know by now, I am an EMR evangelist.  A poorly implemented EMR is a nightmare – slowing people down and increasing frustration.  A well-implemented product, however, will give a huge improvement to workflow in the office, benefitting both doctor and patient.

Here is our EMR in action (with HIPAA censorship present).  I am checking labs on a patient and evaluate their lipids using a Framingham risk calculator that takes the variables from the patient data.  I then generate an email and send it to the patient.  The whole process takes me about a minute (under 30 seconds if I am not recording).  The patients get an email stating that there are results waiting on our server and have to log on securely to view them.  We are notified when they view them and if they haven’t viewed them after 30 days (or whatever interval we determine).

The quick jumps between screens are macros we put on our computers using free software.

Enjoy.

My product is Centricity by GE, but the point is not to push their product, it is simply to show what is possible (and what I do every day with my EMR).

If you want more good information on choosing and EMR or making your current one work better, visit my EMR page.

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Moving to the south is an eye-opening experience.  First, there’s the friendliness of everyone; I remember the first time a stranger talked to me in the grocery store, it made me nervous.  In Philadelphia, where I went to med school, anyone talking to you in the grocery store was either hitting on you or crazy.  Add to that list: “or from the south.”

Then there’s the politeness factor.  Kids are expected to say “yes sir” and “yes ma’am” when answering questions asked by adults.  Most northern-bred transplants to the south that I’ve talked to think this is a good thing – a refreshing change from the rudeness you often get from kids.

But perhaps the most foreign thing in coming to the south is something called “Social.”  Yes, the picture above is from their website.  Social is a manners school where kids are not only taught how to eat right at the dinner table, but also how to address members of the opposite sex and to perform various dances with a partner.  The formal training happens around 6th grade, but the talk of who will get partnered with whom is fodder for many parental discussions for several years leading up to the actual course.  Parents arrange partnerships between their children – kind of like arranged marriages.  My two oldest kids participated in Social (which is run by a local family), and gave it mixed reviews.  We didn’t force it (although we did get calls regarding our kids’ availability), and one of them liked it enough to do it three years, while another barely tolerated one.

All of this came to mind because of a phone call I got this morning requesting an interview about social media and the medical field.  How are doctors handling blogs, Twitter, and Facebook?  What are the guidelines I abide by, and should the professional societies (AMA, ACP, etc)  be involved it directing their members on how to use social media?  The interview was particularly timely because I was working on a post that quoted some funny patient/doctor interactions, but was having second-thoughts due to confidentiality concerns.  How do I quote patient interactions without making it sound like I’m making fun of them?

So, I thought it would be fitting to write my “Ten Commandments of using social media.”  They aren’t really commandments, but I like to feel like Charlton Heston every once in a while.

1. HIPAA is the final say. HIPAA has privacy statutes that set clear boundaries of what can and cannot be said about individual patients.  The bottom line is that the only way we can reveal information about patients to others is by their consent.   Social media has a lot of pitfalls in this area, including: doctors blogging about individual patients and direct communication over Twitter and Facebook about doctor/patient matters.  Breaking this rule is not just an ethical violation, it is a legal one.

2.  Obey the “elevator rule.”  In medical school we were taught the “elevator rule,” which states that you should never talk about patients in the elevator when there is anyone else present.  You must assume you will be overheard.  In the same way, social media is about communicating with a large number of people and so should be used with the same assumption.  Don’t write anything you wouldn’t want your patients to read.

3.  Think before using social media. The lines of what can and cannot be written using social media become gray quite quickly.  Is it OK to talk about people you saw today, or should you wait a few weeks?  What facts do you need to change to make identifying the patient impossible?  What do you want your patients to know about you?  All of this springs from your overall philosophy of using social media.  My blogging is driven by a desire to show doctors to be regular humans, so that is what I write about.  Facebook, on the other hand, is for me to connect with friends (except on my Fan Page, where I interact with readers).

4.  Don’t friend your patients on Facebook. This springs out of rule 3, as there are things patients don’t need to know about me that I want my friends to know.  I want to be able to show vulnerability and frustration.  I am Rob, not Dr. Rob or Dr. Lamberts on Facebook, and I want it to stay that way.  Too many lines can be crossed when friending patients, so I don’t do it.

5.  Beware of Twitter.  Unlike Facebook, Twitter is not a walled-garden.  People can follow you without your permission.  Twitter is a truly public forum that should be seen that way.  The elevator rule definitely applies in Twitter.  I think of Twitter as advertising; we are putting ourselves out there for all to see, letting them decide how worthy we are to be followed or responded to.  The public nature of the forum can be engaging, as can the banter between friends.  But there is a great temptation to post Tweets about frustrating patients after walking out of the exam room, or exposing too much of your feelings for the world to see.

6.  The Internet is Forever.  What I write about using social media is recorded for posterity.  There is no way to take back what you sent over your RSS feed.  Unlike spoken words, which are (usually) gone after the airwaves stop vibrating, everything is recorded on the Internet.  You may not bear the consequences of your writing for years, but it is there to be found once you have written it.

7.  Anonymity is dangerous. I understand why some bloggers choose to remain anonymous, as their workplaces my not understand or appreciate what they do while online.  Yet many anonymous bloggers lose the ethical boundaries holding other bloggers in check.  Anonymous bloggers are much more likely to talk about actual patients, assuming they will never know it’s them and can’t find out.  Early in my blogging career, a blogger who went by the name “Flea” was exposed in court during a malpractice trial.  He had to settle the case.  Anonymity is a very thin shield and invites abuse.

8. Don’t do it for ego. When I started blogging 4 1/2 years ago, I was a nobody.  Pretty soon, however, people started reading my blog and actually liked my writing! This is a big boost to the ego, as is the follower count on Twitter or fans on Facebook.  After struggling with the addictive nature of this ego boost, I went back to my core reason for blogging: showing people doctors are ordinary people.  I go back to that core reason whenever I am led astray by a moment of fame, or a particularly hurtful comment.  This is the only way I could keep doing this for so long.

9. Enjoy the community. Social media is not a contest.  Strive only to be who you are, and enjoy all of the other good writers in the medical blog world.  Some of the best friendships I’ve made over the past 4 years have been through social media.  I learn much from what they write, and really appreciate their different perspective.  This is not “king of the mountain.”  The strength of the blogosphere is its diversity.  Besides, there are some really nice folks out there who write  very well.

10. Share. I have never worried too much about people quoting my content or even republishing it.  Once you put something out there, it is infinitely copiable.  As long as people say who wrote it and don’t take credit, they can use it all they want.  My biggest asset is not my blog or what I’ve written in the past; my biggest asset is my ability to write and express myself.  Nobody can ever steal that from me.  I find it a compliment when people include my stuff in their blogs, it means I am giving something worthwhile to the world.

Kind of like Charlton Heston.

I walk into the exam room and the patient looks up at me with a surprised expression.  ”Wow!  I didn’t expect to see you so quickly!”

I smile and turn around to walk out of the door, saying: “Sorry!  I’ll leave then and come back later.”

“No, no!”  They respond, smiling.  ”I’m happy to see you so soon.  It’s just a surprise.”

I walk back into the room with a smirk.  ”I just don’t want to offend you by being on time.  I’ll try to do better next time.”

I am not sure if I should be happy or sad with such an interchange.  On one hand, it feels good to stay on time with my appointments, holding up my end of the bargain of the schedule.  On the other hand, the patient’s surprise betrays the fact that this is not the usual state of affairs.  And it isn’t.  I generally don’t run on time and don’t expect to run on time.

When I first started practice, the stated objective was to get the person out of the office within an hour of their scheduled appointment.  This seemed a blend of realism and responsibility.  At first it was easy to stay up on things.  My schedule was sparsely filled, so I could make up time.  After sixteen years of practice, however, my schedule almost never has open slots; when it does have openings, they are quickly filled.  I still try to get them out within an hour.

I have patients scheduled, with a few notable exceptions, every fifteen minutes regardless of the appointment reason.  I don’t expect to spend exactly fifteen minutes with people; some will be quick visits lasting 5 minutes and some will take 30.  Usually this averages out to keep me within 30 minutes of the scheduled appointment – something I’ve grown accustomed to.  Some days, however, conspire against my best attempts to stay within a reasonable timeframe.  Everyone is complicated or needy on those days, and I can get 60 minutes or more behind.  I absolutely hate it when that happens.

But as guilty as I feel admitting this fact, I don’t think I will ever change things.  Some docs are obsessed with not falling behind.  I can respect that, but for me it is far more important to give every patient the time that they need.  If I have to spend 45 minutes talking to someone, I do.  My patients have learned this: they will always get my full attention and won’t be rushed.  I do respect the fact that others have their own schedules, but the purpose of the visit is to handle their medical problems.  I don’t want to hurry through a visit so I can stay on time, missing important things that take some focus or detailed questioning.

This is very hard when I am running behind.  It’s hard not to feel rushed when you are already apologetic about being behind, but that is when I am most vulnerable to missing things, and I don’t think people should be short-changed because folks earlier on the schedule took longer.  It all ends up making it hit-or-miss when people come to see me.  Sometimes I am right on time, and sometimes – especially at the end of the afternoon – I am significantly behind.

My long-term patients understand this.  They know they always get as much time as they need, even if it puts me more behind.  They understand that I get behind because of the time I spend.  They know I will chat with them and won’t get rushed.

New patients are usually surprised they get as much time as they do.  This makes me wonder what other docs do, as I am just trying to do what needs to be done.  I suspect it is because I value the personal interaction and rapport as much as I do the medical knowledge.  I am building relationships, so I will always chat, find out what’s going on in people’s lives, and learn about them personally.  Primary care is for the long-haul, and it helps to know as much as possible.

I do write blog posts between patients (like this one), because much of my best stuff comes out of the raw emotion of the office setting.  I try to do it in small chunks, mostly when I’m waiting for people to be brought to the back, or when I’m waiting on some test results.

The bottom line?  I won’t sacrifice being thorough for being on time, and I think one of the biggest parts of being thorough is to talk – even if that talk is about their grandchildren, vacation plans, or job situation.

Gotta go.  Got a patient waiting….

I got a flat tire this weekend.  There were clues that I chose to ignore – the alignment going out suddenly, the steering wheel jiggling when I drove – but the sudden thwacking sound as I sped down I-20 was a clue I couldn’t ignore.  I pulled off, then unknowingly stood in a fire ant bed while I changed my tire.  It still itches.  That’s not the point of this post, but I just needed to gripe a little.

Yesterday we went to the tire shop and found out that not only were both of my front tires worn out, but my rear tires were old and cracked – at least that is what the guy told me.  I went ahead and changed all four tires, leaving the car at the shop for the morning.  About two hours later I got a call, saying that my brake fluid was “really bad,” and that I also needed an air filter changed.  I was suspicious, but I did know I needed the filter, and the charge wasn’t that much.

Car repair places are like this for me.  It always seems that they find something new wrong with my car that needs fixing.  I go in thinking I am going to spend X dollars, and end up spending 2X.  The problem is that I can’t do without the car, and I don’t know enough about cars to do the work myself.  This ignorance causes me to put off getting things fixed on my car, as I don’t like spending money beyond expected.  I don’t wait for the “check engine” light to come on, but the fear of expense, along with the fear of repair men taking advantage of me, keeps me away from auto repair shops.

Sound familiar?

It takes circumstances like this to remind me that my patients can feel the same way.  They come into my office and I order tests, find problems, send them for consults, and prescribe medications.  What would be a relatively inexpensive visit ends up being quite expensive.  Then I tell the patient they need to come back in a month, and they look at me with pleading eyes and ask: “could you make that two months?”

The big difference between me and the car repair place is that most of the ways I rack up the patient’s bill is by sending people other places.  I don’t increase my profits by referring the person to cardiology or by ordering an MRI scan.  I do get a little of the suspicion when I schedule follow-up, but hopefully patients don’t see me as suspiciously as I see the car repairman.  But I am positive that people cancel follow-up visits, avoid preventive care, and don’t take medicines because they don’t think it’s worth the cost.

This is the achilles heel of procedure-based billing.  If I get paid more for doing more, I am financially motivated to do something that may or may not be also motivated by medical need.  Once I come under suspicion of putting my financial interest above the patient’s medical interest, the foundation of care, trust, is undermined.

The decision as to what is necessary and what is not isn’t as clear as it seems.  We used to have access to x-ray equipment for which we made profit from each x-ray we ordered.  To be financially viable, we had to order a certain number of tests, and we would profit significantly by doing even more.  A funny thing happened: I ordered more x-rays.  People with a cough, who I would have previously just watched now got an x-ray.  People with ankle sprains got x-rays as well.  I never ordered them frivolously, but I became increasingly uneasy with the increase.

We no longer do x-rays, and we do only a few lab tests in the office (mainly for convenience).  Many (most?) of my colleagues, however, have bought in to this system that rewards doing more.  Hospital-owned practices exist so that the doctors will order ancillary tests and procedures at their facility.  This is the system that has put down primary care – one that devalues the office visit – and yet we buy into it to offset this devaluation.  Thus far, our office has done quite well without, but the lure of new well-reimbursed procedures is always there.

Some have touted a free-market system where docs post their fees and are paid cash for what they do.  Some feel the solution is the HSA account that pays from a tax-sheltered fund for care.  But I wonder if any cost containment will ever be possible with a system that pays more for quantity, but less for quality.  In this kind of system, the patient is in charge of cost-containement, by rejecting care offered them, by questioning the motives of doctors, and by waiting until small problems become big problems.

It’s very hard, if not impossible, for patients to know if what  is being done is actually necessary.  I don’t know if I really needed my brake fluid changed; I’ll never know.  But I did wait until the tire blew on I-20.

And those ant bites really itch.

Dear Student:

Thank you for your consideration of my profession for your career.  I am a primary care physician and have practiced for the past 16 years in a privately-owned practice.  (At some point I intend to stop practicing and start doing the real thing.  It amazes me at how many patients let me practice on them.)

Anyhow, I thought I’d give you some advice as you go through what is perhaps your biggest decision regarding your career.  Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices.  It is the final choice that is, well, final.  What are you going to do with your life?  ”Being a doctor” covers so much range, that it really has little meaning.  Dr. Oz is a doctor, and he has a very different life from mine (for one, he’s not the target of Oprah’s contempt like I am – but that’s a whole other story).

Here are the things to consider when thinking about primary care:

1.  Do you like talking to people who are not like you?

Primary care doctors spend time with humans – normal humans.  This is both good and bad, as you see all sides of people, the good, bad , crazy, annoying, funny, and vulnerable sides.  If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don’t do it.  The single most important thing I have with my patients that most non-pcp’s don’t have is relationship. I see people over their lifetime, and that gives me a unique perspective.

2.  Do you prefer variety over predictability?

Every room I walk into is different – often vastly different – from the last.  I could be walking in on a crisis or a stable recheck.   The person could be elated or crying.  They could be 90 years, or 2 days-old.  They could have something wrong with any system, and it could range from mild to life-threatening.  I’d go nuts doing the same thing every day, be it looking just at skin or just dealing with the kidney.  But some folks do better with routine and a lack of surprise, they don’t want their days to be unpredictable.

3.  Do you need to be in control?

Primary care is not about control.  Those primary care doctors who try to maintain control of their patients are both unsuccessful and unhappy.  Relationships are not always predictable, and much of what PCP’s do depends heavily on the patient’s “cooperation.”  I put the word in quotes, because the word implies that the doctor’s agenda is more important, an implication that I reject strongly.  PCP’s are part of “team patient.”  Our job is to help them, not direct them.  We give them our expertise and they make the final choice.  Surgeons, on the other hand, don’t consult the patient when operating; they don’t depend on patient compliance as they cut a person open.

4.  Are you a people-pleaser?

The flip-side to #3 is that a PCP must always practice good medicine – even if it makes people mad.  You have to learn to say “no” to people who seek drugs, who want an antibiotic, to drug reps who want you to prescribe their products, and to insurance companies that want you to work for free.  We are not co-dependents.  We don’t base what we do on the reaction we get from patients.  Often we are the only ones with the opportunity to tell them the hard truth about lifestyle choices or about their future health.  I deal daily with the consequences of people-pleasing PCP’s, who addict their patients to drugs, who create antibiotic resistance, or who give in to drug reps and give expensive prescriptions where cheaper ones are better.  Please don’t choose primary care if you are a people-pleaser.

5.  How important is social status?

PCP’s have an interesting paradox in their social status.  In the eyes of the public, we are the ones who earn less money and so must have gotten worse grades than the cardiologists and dermatologists.  In the eyes of those same specialists, however, good primary care doctors have a very large amount of respect.  We are actually the ones who run the medical show, using specialists when we think it is needed.  We need to know 90% of all specialties, and also know when we are in the 10% we don’t know for each of them.  I often get “I could never do your job” from my colleagues.  So if outward social status matters (like what kind of car you drive or how big a house you own), then don’t choose primary care.  I am not saying that PCP’s don’t have a good income (98% of my patients would like my income), just that my outward status is not nearly that of the surgeon who operates only on left ring-fingers.

6.  Do you like puzzles?

The term “gatekeeper” got applied to primary care via our friends in the HMO’s, and that term has haunted our profession since.  Good primary care is not simply triaging people and sending them to those who can offer real care.  Some PCP’s do that, but they are both lazy and unambitious.  I do whatever I can to keep people from the specialists and out of the hospital.  I need to know when to send them, but I also need to know what to do before I send them.  This endears me to my consultants, as I am sending only patients who need their expertise.  I know orthopedists will give an anti-inflammatory and probably order physical therapy for shoulder problems, so I do this before I refer the patient.  80% of my patients avoid orthopedists this way, and the ortho docs know my consults are not usually fluff.

But the real challenge of primary care is the fact that I am usually the first to see a problem.  Specialists get sifted problems – I have already thought the situation through and so they get the left-overs.  I don’t usually send people to specialists for a diagnosis, I send them for a specialized treatment for the problem I have diagnosed or strongly suspect.  I am the quarterback, the manager, the lead singer, the director of the symphony orchestra.

7.  How patient are you?

I have to confess that I was not a beacon of patience when I started practice.  That being said, I have learned that one of the most powerful tools in medicine is waiting. We get to see the big picture.  We see people over months, years, and decades, and watch the progression or deterioration of conditions.  I find this most satisfying.  People who were suicidal ten years ago are now cracking jokes and are productive citizens.  One of the biggest mistakes a PCP can do is to value intervention over waiting.  We are caretakers of the big-picture.  Surgeons do their job in a few hours, radiologists in a few minutes, and oncologists in a few months or years.  But PCP’s do their job over the lifetime of the patient.  To me, that’s a plus, not a minus.

8.  Are you compassionate?

Again, this is something that has developed over time for me, but the seed of it was there early in training.  Primary care is about “care” – in all of the definitions of the word.  We care for people because we care.  It does matter to us that people are hurting.  There is a degree to which primary care is a calling or ministry, not just a job.  There will aways be a necessary detachment we have from our patients (for our own sanity), but a PCP who is simply “punching the clock” is both sad and dangerous.  You need to be able to listen and see things from people’s perspective.  You are their doctor, and they are your patients.  The possession is emotional, it is one of caring.  People judge PCP’s on how much they like them and how well they feel listened to.

There is much more to say (read the rest of my blog, as well as other primary care blogs such as Kevin MD, Musings of a Dinosaur, Jill of All Trades, and DB’s Medical Rants for a more complete picture – sorry to those I left off, there are many other good ones).  Any specialist would tell you that a very good PCP is incredibly valuable.  I love my job, as do many of my colleagues.  I want more PCP’s, but I only want you in my field if you’d raise the average.  We need good PCP’s.

Come join the fun.

So I was walking down the hallway in my office, mildly distracted, when I kicked something.  It was a USB “thumb drive.”  I picked it up and inspected it, trying to figure out who had dropped it.  The side of the drive had a picture that I couldn’t make out, as it was all smudged with something.  I pulled out a tissue and rubbed it, thinking it may be a clue as to whose drive it was.

There was a sudden rushing sound and a strong wind.  Out of the thumb drive emerged a large blue figure wearing a turban.

“Are you a genie?”  I asked

“No, I am David Blumenthal, the health IT ‘czar.’” he responded.

I hung my head down, “I guess this is about the fact that I write the word healthcare instead of health care. I was wondering how long it would be before the feds came down on me for that.

“No, that’s not my realm.  That would be the job of the Department of Language Security, and they’ll be appearing in some creative way next week to get on your case about the whole healthcare thing.  It has Matthew Holt and Maggie Mahar in a big tiff.”

“So why are you here?” I asked, “And why are you doing that whole genie gig?”

“Ah, well president Obama saw that you weren’t using email to communicate with your patients, and he sent me to find out if there was any…ah…persuasion we could do to get you using it.”

“I do use email to communicate with my patients!” I said. “I just don’t do any e-visits, substituting an email dialog for an office visit.  Are you able to fix this problem?”

He got a small smile on his face.  ”That is why Obama sent me in this genie get-up.  He said that I could grant you three wishes on the area of electronic communication with patients.  That’s what I am here to grant.”

“And where did you get the ability to transform like this?”

“Saddam Hussein had a bunch of lamps stored away in his bunkers.  It turns out that instead of weapons of mass destruction, he was hoarding weapons of wish production (known as WWP’s, to us government types).”

“Who’d have thought….anyway, I have three wishes to get to, right?”

“Right.  But don’t wish for more wishes, and definitely nothing to do with llamas.”

“Got it.  Well, you know that I am a big computer geek and an early adopter of technology?”  I asked.

“Your geekiness is known nationally.”

“Great.  Well, the idea of e-communication is not only something I am not against, it is something that I would love to adopt.  The problem is in the payment system, not in the reality of doing it.  I think I could do it without much problem; I just don’t want to start giving things I have made my living on away for free.”

He looked bored and annoyed.  ”I know, I know.  I am as impatient as you about that.  The problem is that our lovely congress is in charge of fixing the payment system.  That’s like asking a toddler to fix a broken vase.  Still, I am a genie now, so maybe we could work something out.  So what are your wishes?”

“My first wish is that e-communication would replace phone communication whenever possible.  Patients don’t like to listen to our Muzak or figure out our voice-mail system, and would much rather send an email than leave a message.”

“I know.  You can only listen to Kenny G for so long.”

“It does bring in business for acute nausea, though.”

“I hadn’t thought of that.  So why don’t you just put a communication link on your website so they can request refills, appointments, and ask questions?” he asked.

“We already do the first two, and the patients are pretty happy with the convenience.  But the last one is the real problem.  If we get into an email conversation with the patient, it is recorded for all posterity.  We are legally liable for anything we write to them and for anything we receive.  With that kind of liability, plus the risk of losing income, we just can’t afford to do it.”

He thought for a moment and said, “So you want me to reform the legal system to reduce your liability?”

“That would be a big start.  We’re humans, and prone to mistakes.  We can’t be looking over our shoulders for the 1-800-SUE-DOCS” lawyers looking to get their windfall.  We need some protection in the day-to-day management of patients.  The use of electronic communication greatly increases documentation, and increased documentation greatly increases potential liability.”

“OK, I’ll get to work on that one.  What’s your next wish?”

“My second wish is that e-visits would replace frivolous office visits. I don’t like to see people for every little cough they have, but many employers require personal office visits for doctor’s excuses.  The schools are even worse at this, ever since the crazy No Child Left Behind legislation was passed.”

“I had an itch on my left behind once.”

“Too much info.”

“Sorry.”

“Anyway, we need to be able to get paid for simple visits that could be handled via email.  We need to be able to get paid for the management of their care as well as the risk we take giving care.  The same holds true for people with chronic disease.  If we could check on people regularly via email, or even by phone, to make sure they were doing OK, then maybe they’d have to come in less and get sick less.”

“The latter sounds like the patient-centered medical home.  People are working on that one.”

“Correction: congress is working on that one.”

“I stand corrected.  So what you want is some sort of payment system that allows dumb visits to be handled electronically.  I think that’s in my power as a genie. I’ll have to ask my boss first.  So what’s your last wish?”

I stood there for a few minutes, scratching my beard and thinking.  ”You know, if the legal side of things got reformed as well as some sort of payment for e-visits, other things would fall into place.  Patients could handle more without coming to the office, so there would be more availability of docs.  Plus, they wouldn’t resist coming in as much if they knew we were willing to handle things online.  I can’t really think of a third wish.  Can I have a rain-check?”

“That’s another thing I’ll ask my boss.  Just don’t take too long, and remember the llama stipulation.”

“That’s a shame, you know.  Having llamas replace those folks in the senate may get things working better than with the folks we have in there now.”

“Llamas in congress?” he asked, eyes widening. “Hmmm…I hadn’t thought of that.  I am sure that the prez wouldn’t mind that one.  I’ll get back to you on that one.”

“That’s alright.  I’m when I hear the passage of pro-poncho legislation I’ll know you’ve done your magic.  Thanks!”

“No problem.  Now, can you click the little switch on the side of that drive so I can go back in?”

I have to confess something to you: I like blogging more than I like podcasting.  There are a number of reasons for this: my podcast has a deadline, my blog does not; my podcast doesn’t have direct feedback from listeners like my blog does; I have more freedom in topic selection for my blog.  But the main reason for this is that I consider my blog an extension of me as a person.  I can express myself in any area of my person, be it humorous, serious, angry, or sad.  Blogging is personal.

So why do I continue to podcast?  One of the main topics I leave off of my blog is medical advice.  I don’t tell you what to do if…whatever.  I don’t explain medical things, instead focusing on the process of seeing a doctor.  My podcast is the vehicle that fills that gap.  I am able to tell listeners (and readers on the website) what I tell my patients in the exam room.  I value having educated patients, finding them much easier to treat than those who just “take my word for it.”  They catch me when I make a mistake.  They ask better questions.  They are more motivated to follow my recommendations because they understand why I am giving them.

The podcast has been a learning experience for me.  On one side I am disappointed that it hasn’t become wildly popular or highly acclaimed.  My blog has surprised me with its popularity, while my podcast has done the opposite, to be honest.  On the other side, however, I feel like I am directly able to help more people through the podcast.  I have a decent following, with a growing base of listeners and an active Facebook fan page (where I get the desired interaction with listeners).  I actually wish it would be used more by docs as a means of quickly educating patients.  I wish more of my own patients would go to the podcast to find out what their doctor thinks about disease X.  But it is also good for me to have to organize my thoughts on each of these problems, think through ways to present them in a manner that is not confusing, and speak them out in a way that doesn’t bore the listeners.

In short, it is good practice for the exam room.  If you haven’t done so, please subscribe to the podcast on iTunes or read it on the Quick and Dirty Tips website.  (To put it bluntly: I am paid based on the number of downloads, so you help me out by doing so.)

Since this is a podcast organized and promoted by Macmillan publishing, the obvious question is about writing a book.  They are quite interested in me doing so, but the process of getting there is slow.  I am OK with that, as I am honestly not chomping at the bit to write a book.  Any book from the QDT side of things would be more along the lines of the podcast than the blog.  It will likely happen within the next year, but I also hope that I can eventually write something that reflects the blog’s perspective.

Either way, I encourage you to get the full picture of things by keeping up with both sides of things.  Tell your friends about the podcast (or your patients, if you are a doc…or your doc, if you are a patient).

Thanks.  I really appreciate you, my readers.

You may have noticed the ads on the site/newsfeed.  I am sorry to those who I offend for wanting to earn some money from blogging.  I am doing my best to keep the ads as reasonable as possible; let me know if there is something way off-base.

Please note that I have a new tab on my homepage entitled “EMR.” This is to give access to the resources of  Software Advice, a company that helps medical offices with the EMR decision-making process.  There are some very good resources on this page (which is why I am promoting them), including information on the “meaningful use” criteria so docs can get money for implementing EMR.  I always advise people to get as much help as possible in the EMR implementation process, and these folks seem to have their act together.

I also have added Scrubs Gallery as a sponsor.  Please note that you can get 15% off mens’ scrubs with code “mens_value”.

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If you enjoy a blog or web page, think about supporting that site clicking on their sponsors’ links.  If I have any link on my website that ever spams you or does you wrong, please let me know so I can eliminate them from my list.  It does cost money to do this stuff, and it takes time away from work and/or family if I am not careful.  I love doing it, but getting something back for the time spent helps a lot.  You don’t do this kind of thing for the money (even my podcast is very modest in what I get paid), but it’s nice to think you are worth some pay (over the $2 per month I can earn from Google Adsense).

Thanks!

From Wikipedia

My recent post on the subject of emails from patients raised more eyebrows than I expected.  It also put me in a position I am unfamiliar with: looking like a luddite.  Perhaps I am not forward-thinking enough in my reluctance to embrace this advance.  Perhaps I have gotten conservative as I grew grey.  Electronic communication is a great idea (I am doing it right now), so why not apply it to my medical practice?  Has Ned Lud gotten into my circle of influence?

This is, of course, extremely ironic.  I lived so much on the cutting edge that my butt developed calluses.  The calluses, however, were not just put there by the edge, they also came from occasional kicking.  The problem is, I have an addiction: I am addicted to change.  I am constantly looking for new and (perhaps) better ways to do things, then impatiently going after anything new and shiny.  This served us well in the sense that I got us on EMR, got it working well, and have continued to keep us away from repeating mistakes too often.  If something doesn’t work, I am quick to look for the cause, and more importantly, how to fix it.

I had all sorts of good ideas, often many at one time.  But this caused problems.  First, the ideas were sometimes stupid.  Stupid ideas don’t always look dumb before they are tried.  Often changes had unintended consequences which made things harder instead of easier.  The other problem was that too many changes at once causes change burn-out.  People get tired of change, even if the changes are just little tweaks to the system.  After a while I realized that I was actually the cause of many of the exasperated expressions I saw in the office.  I understood the following: a good idea at the wrong time is a bad idea. This has become a mantra for me in the office which has allowed me to sit on my hands when I felt the urge to change.

A good example of this is the tablet PC.  Microsoft had the idea 10 years ago, coming out with an operating system built around a touch interface.  Did it catch on?  Not really.  Why not?  Not because it didn’t work – I used these tablets and they did just fine – but because they didn’t fix an important enough problem.  So are tablet PC’s a bad idea?  Not anymore; ask apple (and the 20 gazillion apple disciples who stood in lines for iPads).

So what about email consults?  Why not take email from patients when it would suffice as an alternative to coming in to the office?  It would save us hassle (I don’t want to see people for unnecessary stuff), would potentially make money (some insurance does pay for it), and make patients happy.  Sounds great.  I want to do it.

But a good idea at the wrong time is a bad idea. We are already emailing labs, allowing patients to request appointments and refills electronically, and getting ready to make some of the medical record available 24/7 online for all of our patients.  We are also in the process of complying with “meaningful use.”  We are upgrading our system to a newer version.  Our plate is full.

But even more importantly, we need to continue offering care.  We have to keep this plane flying while we rebuild it.  People are getting sick and wanting care while we attempt to change.  Implementing e-visits is a huge task – very disruptive of our current processes.  In the long run this should be a good thing, but one of the main reasons we have been successful in not only adopting EMR, but also being quite profitable as a private primary care office, is that we approach change very cautiously.  The bigger the change, the more planning is required.  We do change; we just take time to make sure we do it well.

That’s not Luddism, it’s being careful.

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