The Poor Historian

Credit Shelbyroot on Flickr

Last week, I was listening to the cases that were admitted by the overnight resident. By the time he presented the third case, I became annoyed after I repeatedly heard the dreaded phrase “poor historian.” This particular patient wasn’t forthcoming with his symptoms. He was vague with what was going on. “He couldn’t provide an accurate history.” The patient was a homeless man who came to the emergency room feeling unwell and coughing up blood. He had a rip-roaring pneumonia.

I stopped the resident and told him bluntly “the reason the patient can’t give a history is because he is very sick! You too would give a poor history, if you had strep pneumonia bacteria coursing in your blood. ”

The resident had also incorrectly used the term. The historian is the by definition, the one who takes the history. The resident had done a poor job and had blamed the patient for his own deficiencies.

In Jayshi’s Patel JAMA’s piece “The Things We Say” he recounts his own experience with this term.

Later, when I ignored the term and began to pay attention, I concluded encephalopathy, dementia, depression, frustration, anxiety, and anger were reasons why patients did not provide an accurate history. In fact, there was always a reason why the patient wouldn’t or couldn’t provide a history. I learned that a patient’s inability to provide a history should not limit my ability to correctly obtain one.

Whenever I hear the phrase poor historian, I try to teach that there are always ways to get a thorough history. There is collateral history we can take from a patient’s family and friends. There are written notes by the paramedics who are usually the first to the scene. There are old medical charts and electronic records we can peruse. We can examine the patients and phrase our questions in ways they can understand and respond to. Rather than grilling the patient, “we can use open-ended questions, pauses, silence, and active listening, to allow the patient to tell the whole story” writes Dr. Tiemstra. The historian isn’t just a scribe – they are the person who organizes the past events and details, and reorganizes the story in a way that makes sense.

When I went to see the patient in the emergency room, I saw a man who was lethargic and breathing hard. “I feel sick doc,” he said in a weak voice. There was nothing more needed to be said. He had given me an accurate history.

The Attending Life

I have been teaching a lot of medical students and residents lately as the “attending / staff” physician. It’s hard to remember what it was like ten years ago, when I was an undergraduate student and clueless about the world of medicine. I was naive and green. Optimistic and cautious. I didn’t even know how much I didn’t know. At least now, I know that I don’t know a lot.

A few afternoons, I went over some non-medical  topics that the students and residents really enjoyed, so over the next few months, I will try to find time to write and post them. One, so I have a reference I can use again and again, and second, maybe someone will find it useful too.

They include topics such as

  • Physician Finances – a topic I’ve been reading and learning a lot about
    • The most important rules for financial independence
    • Understanding lifestyle inflation / creep
    • Ways doctors can be smarter with their money
  • Building a Career
    • How to find and get a job successfully
    • Crafting your career into what you want
  • Studying – how to integrate into a busy rotation / residency / practice
    • how to build systems and confidence about your medical knowledge
    • Update on websites / apps / tools I use in my day to day

In other news – Life has been good. New city, new job, great opportunities, growing family. It’s been so fast that I haven’t had time to reflect. I will have to re-read some old posts as I start to revamp and clean up this blog.

New Chapter, New Beginnings

Life as an attending physician has been everything I had hoped it would be. I’ve been out of residency a year so far and I am loving my job – the autonomy, the colleagues, the patients, the medicine. As always, there are some aspects that aren’t as pleasant to deal with such as scheduling, overnight calls and difficult patient encounters, but on a whole, post-residency life has been good. However, there is one thing I had as a resident that I don’t quite have yet as an attending and that’s clear career goals.

Let me explain. Throughout medical education, there was always a clearly defined goal : graduation. I was willing to put in the effort in mastering my craft because I knew one day I would have to use these skills to help others.

Ten years ago, when I first received my medical school admission letter, I experienced a mixture of joy and relief. The relief was mainly from not worrying about what my future trajectory would look like, I knew more or less my 20s would be spent in medical school and residency to become a doctor.

Having finished those grueling years, I look forward and realize my career in medicine will be many times longer than my training. This leads me to the question, what do I want my career to look like and how will I get there?

There are aspects that I’ve already defined and shaped, with which I am happy about. I am practicing the specialty of my choice (internal medicine). I work in a blended academic and community hospital, having plenty of contact with medical trainees while getting my hands messy with front line care.  I am rewarded handsomely and will be financially secure.

Yet that same feeling of unease and uncertainty about the future that I felt as a pre-med, I feel now as an attending. In Daniel Pink’s book Drive, he argues that human motivation is largely intrinsic and consists of autonomy, mastery, and purpose. The first two aspects come easily in my day to day job. I have lots of control over my clinical work, and there are lots of skills I am continuing to master. However, tt’s the last aspect a purpose, or being part of something bigger, which is on my mind.

Don’t get me wrong, I find a lot of gratification and purpose in my clinical work. I love making the right diagnosis and having the right knowledge and abilities to alleviate suffering. But what I want to know is can I do more, and if so, how can I use my unique abilities to do so?

In my clinical work, I can improve or save a life one at a time, but my time and abilities aren’t scaleable. Would I be satisfied with Talmud’s quote “And whoever saves a life, it is considered as if he saved an entire world”, or do I believe I can affect more change.

Ultimately this is mixture of nervousness and excitement. No longer am I bound to a prescribed rigid timeline. I want my career to continue to evolve, what it will eventually look like, I’m not sure yet. But I know I would be extremely disappointed if the next ten years looked identical to my past year. I want to continue to grow, learn more and affect positive change. To keep pushing the boundary, and use my role as a doctor to be part of something bigger.

Agent+ App Review – Billing for Doctors on the Go

One of the contentious topics you don’t learn much about in your transition to staff physician is income and medical billings. At the end of residency, different billing companies and agents often host dinners and info sessions to try to woo you to use their service. It can be quite confusing.

Luckily during my residency I worked with a physician who developed a billing app (Agent+, iOS only) that is intuitively easy to use and caters to the mobile first mentality of new graduates. I currently use Agent+ and think it’s a great product, so I thought a review would be fitting.

The premise is simple: why fill out billing cards to give to your agent when you can get it all done on your phone in real-time. Less hassle, more control of your billings, more earnings for you.

agentapp-animation

Review of the App

Pros:

  • Clean interface
  • Security – have your billings on you at all times and never worry about losing your sheets anymore – unless you lose your phone!
  • The Rounds List feature makes billing on recurring patients simple. I can do my billings for 20+ patients in a few minutes.
  • Search makes finding referring physicians, diagnostic codes. and billing codes quick.
  • Real-time billing – instead of having a lag time of going home to input your billings on a computer program or to give your sheets to an agent, you can submit everything through the app and it’s done.
  • 1% fees – the lowest I’ve seen
  • Helpful support staff

Cons

  • only on iOS currently, Android users will have to wait for the next release
  • Only for OHIP (Ontario Billings)
  • Minor bugs here and there – particularly with the referring physician list. Occasional crashes. But updates are frequent and they have excellent support.
  • Inputting NEW claims can be a bit smoother. Currently takes about 30-45 seconds, but I can’t see why it can’t be trimmed down to half the time with better design.

Conclusion

Mobile apps will be the way of the future for billings. With a rate of 1%, real-time submission and more consistent with our mobile lifestyle, Agent+ provides a great product that will only improve with time.

I would recommend downloading the app (it’s free) and playing with the interface. If you think you may use it in the future, submit a claim before Dec 31, so that you can be locked in to the early-adopters rate. The first claim is waived free anyways. Mention by sharecode TIMC22 to receive two months of billings free.

Disclaimer: I personally use Agent+ for my billing. If you join using my referral (share code TIMC22) – we both receive two months of billings free.