Direct primary care for the poor

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A third-year family medicine resident inquires about the direct primary care model (DPC) and caring for the poor. (more…)

Book review: How Doctors Think

By Kathryn Montgomery

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Kathryn Montgomery’s How Doctors Think: Clinical Judgment and the Practice of Medicine is an excellent book that was brought to my attention by Dr. James Gaulte in the comment section of my post on phronesis.  Indeed, much of Montgomery’s monograph deals with the Aristotelian concept of practical wisdom applied to clinical decision-making.

The author is Professor of Medical Humanities and Bioethics and Professor of Medicine at Northwestern University Feinberg School of Medicine.  Her book is too rich to cover deeply in a short review, but I’d like to highlight some of its major strengths as well as a few minor weaknesses.

In the first part of the book, Montgomery thoroughly demolishes the notion that medicine is applied science.

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A prospective medical student asks for advice

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A prospective medical student wrote me this, and below is my response: (more…)

Maintenance of board certification

Who is thriving and who is struggling?

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Nov-Dec-15-Web 1This article first appeared in the November/December issue of San Francisco Medicine, the magazine of the San Francisco Medical Society. That issue was dedicated to the theme of ‘Thriving in Medicine.’ For other blog posts on the topic of MOC, see here.

Up until recently, obtaining and maintaining a specialty board certificate seemed essential for a physician intent on having a thriving medical career.  Doctors and the public alike widely viewed board certification as a proof of proficiency that distinguished those with advanced training and expertise.

To maintain board-certified status, certificate holders were quite willing to be subjected to a decennial examination, and some doctors even looked forward to preparing for the test and to an opportunity to systematically review their field of expertise.

In a few short years, however, any positive sentiment regarding maintenance of certification (MOC) exercises seems to have all but evaporated.

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Medical friendship at the end of life

As hard as it sounds

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Pat, a non-physician reader, writes:

I read your two articles on friendship for more explicit clues on how to deliver very bad news, and wondered if you would consider publishing something on this topic as part 3 of this series. My prompt is a close friend with cancer, and she’s not getting better. At her last visit, the message she took home was: “there’s not much more we can do for you other than more chemotherapy, and we’re not even sure that it will do any good.”   This was a complete and sudden loss of hope.

Two thoughts come to mind.

The first is from Viktor Frankl. In Man’s Search for Meaning he says: “Those who know how close the connection between the state of mind of a man – his courage and hope, or lack of them – and the state of immunity of his body will understand that the sudden loss of hope and courage can have a deadly effect.”

The second is from Atul Gawande’s book, On Being Mortal. He describes two approaches to giving bad news. Dr. Informative supplies hard cognitive information: cold facts, descriptions, outcome possibilities, statistics. A doctor’s other approach might be to look for an opportunity to start the conversation with “I’m worried” and then continue with the patient in an “ask, tell, ask” process. In this approach, the direction of travel becomes clear more gently and perhaps gives the patient a little more time to walk into the possibility than being crashed into it.

…I would be especially interested to read your views from the doctor’s side in the context of your two blogs on the friendship dimension in the doctor-patient relationship.

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The physician as entrepreneur

Warning: not a post about "disruptive innovators"

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Frank Knight, risk and uncertainty

In this article, I wish to introduce the reader to the theory of entrepreneurship advanced by Frank Knight (1885-1972), and show that the common, everyday work of the physician could be considered a form of entrepreneurial activity in the Knightian sense.

Knight was an influential American economist.  He is best known for his book Risk, Uncertainty, and Profit in which he proposed to distinguish risk and uncertainty as follows:

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Interview on “The Price of Business”

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A couple of weeks ago I was interviewed by Kevin Price on his radio show “The Price of Business” which runs on Houston’s 1110 AM KTEK radio station.  Also present was Dr. Geetinder Goyal.  We talked healthcare economics, free markets, and direct patient care.  I hope you enjoy it.

Good medicine starts with friendship

Advice from the ancients

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Whenever I have the opportunity to suggest that good medicine is based on friendship, I usually get a nod of approval mixed with a quizzical look.  What’s that supposed to mean?!

At a recent meeting of an editorial board on which I serve,  the reaction to my suggestion was more forceful and perhaps more honest.  The topic of the day concerned patient education, and how hard it can be to move patients to do things like exercise more or eat better.  I timidly proposed that, as physicians, we might want to start by being our patients’ friends.  The physician sitting next to me immediately objected: “I wouldn’t go that far!”

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How to safeguard your career in a treacherous healthcare environment.

Economics, ethics, and philosophy for medical students

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the following post is a slightly edited version of an article kindly commissioned by In-Training,  a website run by and for medical students. The advice I give in the article is based on lessons I learned long after finishing medical school, so I hope you will find this piece of interest, even if you are well established in your healthcare profession.

Dear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.”  I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice.  I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions.  The real advice will come to you naturally as you proceed to answer these questions for yourself.  I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career.  I hope that you, in turn, will find them intriguing and worth investigating.

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How doctors became subcontractors

In our healthcare system, the "middleman" is not who you think

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During my recent podcast interview with Jeff Deist, president of the Ludwig von Mises Institute, I remarked that third-party payers are not, in fact, intermediaries between doctors and patients.  In reality, it is the physician who has become a “middleman” in the healthcare transaction or, as I argued, a subcontractor to the insurer.

Important as it is, this reality is not well recognized—not even by physicians—because when doctors took on this “role” in the late 1980s, the process by which healthcare business was conducted did not seem to change in any visible way.

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