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If we can't embrace change, let's learn to accept it


New medicines, new techniques? Hallelujah! saysthis veteran doctor. Automated phone systems? Don't ask.

If we can't embrace change, let's learn to accept it

The Way I See It

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Choose article section...Diagnosis: Is the thrill really gone?Whatever happened to time at the bedside?Press 1 for Dr. Smith: This is progress?

By C. Basil Williams, MD

New medicines, new techniques? Hallelujah! says this veterandoctor. Automated phone systems? Don't ask.

Futurist Alvin Toffler challenged all of us to recognize that changeis inevitable and should be embraced. But some people simply can't adjustto change. In fact, it's been playfully suggested that enclaves be createdfor such Luddite souls, with time frozen at, say, 1950.

Many physicians might warm quickly to that idea. We've been known toembrace change with something less than a bear hug. But the reality is,we need to prepare for and accept change, which has taken place at a tumultuouspace in medicine in recent years.

Some of the changes are beneficial to all; others are dubious. Our reactionsto them are crucial to our survival. We needn't meekly submit to the juggernaut--infact, our own creative responses can help shape change for the better.

I can think of three situations where change has threatened to subvertmy own sense of equilibrium and well-being as a physician. As the once-familiarterritory of my practice swells and heaves beneath me, I do my best to adaptand find a way to solid ground.

Diagnosis: Is the thrill really gone?

I still remember the excitement of making my first diagnosis of parathyroidadenoma. It was 1963, and I'd just finished my internal medicine board exams,which were peppered with disorders of calcium metabolism.

When a patient presented with hypertension, intractable ulcer symptoms,and headaches, I thought: "hyperparathyroidism." But, suspectingI was overly sensitized to the boards, I ordered an upper GI series anddidn't ask for a calcium level. The duodenal ulcer was well demonstrated,but the incidental finding of nephrocalcinosis made me suspect a parathyroidtumor. A calcium value of 13.8 clinched the diagnosis. Removal of the adenomacured the man's ulcer and prevented further renal stones.

Today, such excitement no longer comes readily. I've identified fourparathyroid tumors in the past five years, but none by my own clinical acumen.Elevated calcium levels just pop up on the multiphasic screens everybodygets, and what was once a tough diagnosis is now a routine discovery.

Though it's not much of a thrill these days to see an elevated calciumin an asymptomatic patient, deciding what to do about it still taxes mybrain. I now focus on the decision-making and patient education opportunitiesprompted by the diagnosis. And while I appreciate practice protocols, Itry to prevent them from minimizing my thinking.

On balance, the advances in diagnosis ought to be easy for us all toembrace. Our hospital recently implemented a heparin protocol for treatingthromboembolic disorders. Using a standardized dosing protocol and coagulationtesting, we now can hit our therapeutic targets much faster, and I am sparedthe 2 am phone call to order the next dose. It's a little demeaning, I mustadmit, to discover that the 24-hour pharmacy can do the job faster and betterthan I can. Although I didn't welcome this change initially, I now acceptit wholeheartedly.

We should revel in the tremendously more sophisticated diagnostic andtherapeutic modalities available to us. Letting a cardiac ultrasound unravela diagnosis that once required an invasive catheterization is a cost-saving,time-saving bonus. It's easy to grouse about keeping track of the cephalosporinof the month, but having a potent oral antibiotic that achieves a cure withfive days of a once-a-day pill is far better than relying on 10 days ofa four-a-day pill.

Whatever happened to time at the bedside?

I started in practice four years before the advent of Medicare. WhenI walked on the hospital ward, the nurse, in white cap and spotless whiteuniform, handed me a patient's chart with careful, handwritten summariesof vital signs, up-to-date lab and X-ray reports, and succinct nurses' notes.

Now when I arrive, I see the backs of nurses' heads as they crouch overtheir keyboards. I have to sit at my computer terminal and tap out commandsto input about 12 pages of data. Much of the information is extraneous,but I can't take a shortcut.

I'm reasonably computer literate, but my rounds take twice as long nowas I steal time from the bedside to work with the machine at each nursingstation. The nurses are busy inputting their observations--again, spendingless time at the bedside--and I'm told this is progress. Most of what bedsidecare remains is now given by LPNs and aides.

I've tried repeatedly to get the ward clerk to print hard copies of patientcharts every morning before rounds, but so far that gets done only on theICU. The regular units say they don't have the staff to do it. Well, maybe.An older internist friend of mine flatly refuses to push a single key ona terminal. He cajoles the head nurse to bring up his data--and he getshard copies, too.

I could save time by using the bedside screen to look up data. But thatsuggests to the patient that I'm more interested in the machine than inhim. I used to review the patient's chart by the bedside, but there's solittle in it now that it doesn't make sense.

The computers produce copious legible data, and I suspect they reduceerrors--but at a cost. They require more of a physician's time, and theydepersonalize. And I doubt they save any money.

I've tried to adapt by simply accepting that it takes longer to round,and by taking time whenever I can to speak face to face with patient andnurses. We cannot afford to lose the art of human communication.

Meanwhile, I'm trying to be less recalcitrant about computers. I discardedmy Smith Corona for a word processor years ago, and when I "graduated"from private practice recently, my children upgraded my PC and gave me ayear's subscription on the Internet. I'm now quite comfortable surfing theNet and learning the ropes of e-mail. And I admit, having a computer makesit easier to keep track of the cephalosporin of the month.

On the other hand, I haven't replaced the little red book I always carryin my shirt pocket with a handheld computer--at least not yet.

Press 1 for Dr. Smith: This is progress?

Some changes, I'm convinced, do not represent progress. They must beresisted, or at least channeled.

I rail at automated phone systems, for example. Recently, I called areferring doctor at his clinic and listened as a recorded operator endlesslyrecited my six numerical choices. When I punched number 5 for Drs. A, B,and C, I got another choice about making an appointment or reviewing myaccount. It took four minutes for me to reach a live voice.

When I discovered in a staff meeting that our own administrator was thinkingof a similar system ("it's more efficient"), I hit the roof. We'vesince adopted a modified system that keeps a live person as the patient'sfirst contact. Calls come in to our operator and are directed to our nursingstations. If the operator or the nurses are busy, patients get a messagetelling them--nicely--to hold and their call will be picked up as soon aspossible. Nobody gets a busy signal, and we do not make patients "press1 for this, press 2 for that."

My answering machine at home is a good substitute for the answering serviceI gave up when I left private practice. Caller ID is marvelous. I no longerrespond to the "anonymous caller" interruptions at mealtime assomeone hawks another credit card or invites me to refinance my nonexistentmortgage.

It's wise--and somehow reassuring--to recognize that some changes inmedicine fall flat. I still remember the gastric freezing technique that,30 years ago, was going to revolutionize the treatment of peptic ulcers.A large balloon was placed in the stomach and a freezing solution circulateduntil the parietal cells were killed. Voila! No acid, no ulcer. It was agreat idea, but it flopped when stomachs ruptured and regenerating parietalcells ensured recurrences.

In the last few years, at least four promising new drugs had to be takenoff the market because they produced untoward side effects. I'm remindedof the old saw: "Don't be the last to adopt a new drug or procedure. . . but don't be the first, either!"

There's no such creature as a sure thing. A successful physician is onewho recognizes and anticipates changes, adapts in a healthy manner, andgoes on about life. Frozen in time? Nah, we'd miss all the excitement.

The author, an internist, recently retired from office practice andnow serves as a consultant and clinical trials investigator in Ogden, UT.He is a Contributing Editor to Medical Economics.

C. Basil Williams. If we can't embrace change, let's learn to accept it. Medical Economics 1999;16:145.

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