Medical practice Archives - Page 2 of 4

Book review: How Doctors Think

Michel AccadMay 4, 2016December 13, 2016Medical practice, Medical science, Philosophymedical decision-makingLeave a comment

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.Continue reading “Book review: How Doctors Think”

Maintenance of board certification

Michel AccadFebruary 5, 2016September 10, 2021Healthcare policy, Medical practicemaintenance of certification7 Comments

[This 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.Continue reading “Maintenance of board certification”

Medical friendship at the end of life

Michel AccadJanuary 20, 2016December 13, 2016Medical practicefriendship1 Comment

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.

Continue reading “Medical friendship at the end of life”

The physician as entrepreneur

Michel AccadDecember 4, 2015December 13, 2016Healthcare economics, Medical practice, Medical sciencedoctor-patient relationship, medical decision-makingLeave a comment

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:Continue reading “The physician as entrepreneur”

Good medicine starts with friendship

Michel AccadNovember 20, 2015December 13, 2016Ethics, Medical practice, Philosophydoctor-patient relationship, friendshipLeave a comment

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!”Continue reading “Good medicine starts with friendship”

How to safeguard your career in a treacherous healthcare environment.

Michel AccadNovember 13, 2015September 10, 2021Ethics, Healthcare economics, Medical practice, Medical science, Philosophy7 Comments

[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.Continue reading “How to safeguard your career in a treacherous healthcare environment.”

How doctors became subcontractors

Michel AccadOctober 27, 2015December 13, 2016Healthcare economics, Healthcare policy, Medical practicedoctor-patient relationship2 Comments

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.Continue reading “How doctors became subcontractors”

Neither expert nor businessman: the physician as friend.

Michel AccadOctober 15, 2015December 13, 2016Ethics, Healthcare policy, Medical practice, Philosophydoctor-patient relationship, friendship, outcomes2 Comments

In a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument? For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third. In other words…outcomes!Continue reading “Neither expert nor businessman: the physician as friend.”

Five hopeful trends in medicine and healthcare

Michel AccadOctober 8, 2015December 13, 2016Medical practice3 Comments

I feel that I have been spending way too much time as a “chronicler of the decline,” to use von Mises phrase. The secular trend in healthcare (literally spanning the last 100 years) is one of increasing centralization, consolidation, and reduced choice. Nevertheless, there are some promising developments that gives me hope for a better future.

Here are five notable trends, in no particular order:Continue reading “Five hopeful trends in medicine and healthcare”

Phronesis

Michel AccadAugust 13, 2015December 13, 2016Ethics, Medical practice, Medical science, Philosophymedical decision-making3 Comments

I told you before that I would do my best to avoid bringing up phronesis, but a superb essay by Lisa Rosenbaum, national correspondent at the New England Journal of Medicine, is forcing my hand.

In “The Paternalism Preference — Choosing Unshared Decision Making,” Rosenbaum calls into question the gradual shifting of the burden of decision-making onto patients in the name of informed consent and autonomy.

The essay begins by examining the issue from the patient’s perspective, but Rosenbaum’s reflection then turns to the role of the physician. She remarks:

But science cannot answer a question at the core of our professional identities: As information-empowered patients assume greater responsibility for choices, do we assume less?

The answer to that question has to do with our understanding of what constitutes good medical decision-making. Clearly, the prevailing notion assumes that good medical decisions come after a rational approximation of an objective biological reality, a “predictive analysis” that forms the core of “evidence-based medicine.”Continue reading “Phronesis”