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A doctor discovers an important question patients should be asked

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This patient isn’t usually mine, but today I’m covering for my partner in our family-practice office, so he has been slipped into my schedule.

Reading his chart, I have an ominous feeling that this visit won’t be simple.

A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath.

He suffers from both congestive heart failure and renal failure. It’s a medical Catch-22: When one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.

Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can’t blame him.

 Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.

With us is his daughter, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.

After 30 years of practice, I know that I can’t possibly solve this man’s medical conundrum.

A cardiologist and a nephrologist haven’t been able to help him, I reflect, so how can I? I’m a family doctor, not a magician. I can send him back to the ER, and they’ll admit him to the hospital. But that will just continue the cycle. . . .

Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it’s useless to try.

Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?”

I pause, then look this frail, dignified man in the eye.

“What are your goals for your care?” I ask. “How can I help you?”

The patient’s desire

My intuition tells me that he, like many patients in their 80s, harbors a fund of hard-won wisdom.

He won’t ask me to fix his kidneys or his heart, I think. He’ll say something noble and poignant: “I’d like to see my great-granddaughter get married next spring,” or “Help me to live long enough so that my wife and I can celebrate our 60th wedding anniversary.”

His daughter, looking tense, also faces her father and waits.

“I would like to be able to walk without falling,” he says. “Falling is horrible.”

This catches me off guard.

That’s all?

But it makes perfect sense. With challenging medical conditions commanding his caregivers’ attention, something as simple as walking is easily overlooked.

A wonderful geriatric nurse practitioner’s words come to mind: “Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function.”

Suddenly I feel that I may be able to help, after all.

“We can order physical therapy — and there’s no need to admit you to the hospital for that,” I suggest, unsure of how this will go over.

He smiles. His daughter sighs with relief.

“He really wants to stay at home,” she says matter-of-factly.

As new as our doctor-patient relationship is, I feel emboldened to tackle the big, unspoken question looming over us.

“I know that you’ve decided against dialysis, and I can understand your decision,” I say. “And with your heart failure getting worse, your health is unlikely to improve.”

He nods.

“We have services designed to help keep you comfortable for whatever time you have left,” I venture. “And you could stay at home.”

Again, his daughter looks relieved. And he seems . . . well . . . surprisingly fine with the plan.

I call our hospice service, arranging for a nurse to visit him later today to set up physical therapy and to begin plans to help him to stay comfortable — at home.

Back home

Although I never see him again, over the next few months I sign the order forms faxed by his hospice nurses. I speak once with his granddaughter. It’s somewhat hard on his wife to have him die at home, she says, but he’s adamant that he wants to stay there.

A faxed request for sublingual morphine (used in the terminal stages of dying) prompts me to call to check up on him.

The nurse confirms that he is near death.

I feel a twinge of misgiving: Is his family happy with the process that I set in place? Does our one brief encounter qualify me to be his primary-care provider? Should I visit them all at home?

Two days later, and two months after we first met, I fill out his death certificate.

Looking back, I reflect: He didn’t go back to the hospital, he had no more falls, and he died at home, which is what he wanted. But I wonder if his wife felt the same.

Several months later, a new name appears on my patient schedule: It’s his wife.

“My family all thought I should see you,” she explains.

She, too, is in her late 80s and frail, but independent and mentally sharp. Yes, she is grieving the loss of her husband, and she’s lost some weight. No, she isn’t depressed. Her husband died peacefully at home, and it felt like the right thing for everyone.

“He liked you,” she says.

She’s suffering from fatigue and anemia. About a year ago, a hematologist diagnosed her with myelodysplasia (a bone marrow failure, often terminal). But six months back, she stopped going for medical care.

I ask why.

“They were just doing more and more tests,” she says. “And I wasn’t getting any better.”

Now I know what to do. I look her in the eye and ask:

“What are your goals for your care, and how can I help you?”

Kaminski, a family physician for 30 years, is medical director for AtlantiCare Physician Group in southern New Jersey. This article first appeared in Pulse, a New York-based online magazine that publishes personal accounts of illness and healing

No Doctor Should Work 30 Straight Hours Without Sleep.

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The American medical system requires dangerous feats of sleep deprivation. It doesn’t have to.

When Larry Schlachter was a 31-year-old neurosurgeon, he was driving to the hospital early one morning and “just blacked out.” He crashed his car and crushed his chest; broken ribs punctured his thorax, which filled with air and blood. “I almost died.”

Instead he was left with 14 fractured bones and a lingering loss of balance. He attributes the blackout to working 120-hour weeks that left him often on the brink of awareness. He put it to me clinically: “I was a victim of physician fatigue and exhaustion.”

Getting five or six hours of sleep—substantial by many physicians’ self-standards—can leave drivers impaired to a degree that’s similar to drunkenness. That’s according to findings of a study released this month from the AAA Foundation for Traffic Safety: Drivers who sleep only five or six hours in a 24-hour period are twice as likely to crash as those who got seven or more.

The finding led AAA’s director of Traffic Safety Advocacy and Research Jake Nelson to recommend on NPR:“If you have not slept seven or more hours in a given 24-hour period, you really shouldn’t be behind the wheel of a car.”

So, should you be performing neurosurgery?

When the young Schlachter did come back to work, his damaged vestibular system proved less than optimal. “I lost my balance and just fell on top of one or two patients in the operating room,” he recalls.

Even if a surgeon doesn’t physically collapse on top of a person, drowsy doctors are more likely to experience lapses in memory and judgment that can prove critical. In other words, the brains of doctors are subject to the limits of physiology in much the same way as other human brains.

In this month’s issue of The Atlantic, I wrote about my experience with sleep deprivation during medical training, and since publication, I keep hearing iterations of the same response—a version of what this caller asked on a Wisconsin Public Radio show on which I was a guest yesterday: “I remember 30 years ago in a human physiology class, it seemed like there was a good understanding then of sleep cycles and how harmful it can be to mess them up. I wonder why the medical profession—the one that should understand this the best—seems to be the one that kind of abuses this the most?”

It’s an especially timely question, because right now things stand to get only more extreme for medical residents. The organization that makes the rules for medical trainees—the Accreditation Council for Graduate Medical Education (ACGME)—is proposing increasing the current number of consecutive hours that young doctors can work, from 16 hours to 28 hours.

When I was a medical intern (the first year after graduating medical school) in 2009, the limit for people in my position was 30 continuous, sleepless, busy hours. The Institute of Medicine had issued a report the year prior saying that was unsafe. At the request of Congress, the physician body had audited the ACGME rules and said that the limit for shifts should be 16 hours. (Or 30 hours with a “5-hour protected sleep period” in the middle. Which sounds meager, but there were times I would have sold my soul for even 20 minutes of sleep.)

In 2010, the ACGME changed its rules accordingly—for first-year residents, at least. Hearing that, I thought I’d be the last class to have his first-ever hospital shift be 30 hours in the ICU. That mix of panic, inadequacy, and exhaustion that I wish on no person—for the new class, that would simply be a mix of panic and inadequacy. The exhaustion from 16-hour days would be more chronic than acute.

But now the ACGME is proposing raising that limit back up to 28 hours. The group is currently accepting public comments on proposed revision, until December 19. After that, the task force will use the comments to inform final recommendations.

I asked the ACGME why this is happening. The group’s spokesperson said no one was available to talk to me for a few days, but they were happy to answer my questions in written form, which they did (and that’s why the quotes here sound stilted).

The group said the 28-hour maximum is “based on new evidence, research and expert input.” At a national meeting in March of 2016, the ACGME  heard perspectives from specialty societies, certifying boards, patient-safety organizations, resident unions, and medical student organizations. Among the new evidence since 2011, the most influential study was a large survey of surgical outcomes. Published earlier this year The New England Journal of Medicine, it found that for surgical residents, “Less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications.”

The study began in the fall of 2014, when Northwestern researchers compared programs that allowed residents to work longer shifts. They also didn’t have to be given eight hours off between shifts, or 14 hours off after a 24-hour shift. In these hospitals, rates of death and surgical complication were comparable. So the authors concluded that “flexible duty-hour policies for surgical residents were non-inferior to current ACGME duty-hour policies with respect to patient outcomes.”

Of course, non-inferior does not mean superior. The study did not compare the actual hours worked by residents, only the guiding policies; and it didn’t assess the effects of exhausted residents on nurses and other clinical colleagues, who may have served as safeguards against error. The trial also didn’t test the 16-hour versus 28-hour maximum. Another trial is doing that currently—called iCOMPARE, it is a large collaboration between the University of Pennsylvania, Johns Hopkins University, and Harvard Medical School. But those results are not yet known.

Nonetheless, the ACGME has decided to propose repealing the 16-hour cap for first-year residents. As the group explained it to me, the cap “may not have had an incremental benefit in patient safety, and there might be significant negative impacts to the quality of physician education and professional development.” Letting first-year doctors work 28 hours “puts first-year residents on the same schedule with other residents, and is a commitment to team-based care and seamless continuity of care that promotes professionalism, empathy, and commitment among new physicians.”

In other words, that’s the culture. Patients and colleagues feel bad, and you will, too. That may be less absurd than it sounds. Even Schlachter agrees this cultural component is important. Part of medical education is teaching dedication. “I should be at the front of the line saying that residents shouldn’t be pushed to the point where they can’t take care of themselves,” Schlachter told me, “or when their safety is endangered.”

He injured his hand several years ago and had to give up neurosurgery, so he went to law school and now works as a medical malpractice attorney. In that capacity, he is profoundly critical of hospital culture. But ultimately he’s on the fence about the work-hour restrictions: “When I came up, we worked 120 hours a week as residents. We were committed—it was like Marine boot camp. But that kind of training follows through into your care of patients. Things have evolved now to the point where doctors are shift workers. They don’t care as much. They don’t feel that responsibility as much.”

Is so many hours in an inpatient setting really what takes to teach dedication, responsibility, and commitment? Especially when most American illness is chronic, and the most cost-effective and underutilized solutions are preventive? Are other professions—where people sleep at night, every night—failing to instill dedication?

And what about the health and safety of young physicians? The evidence that sleep deprivation is a serious health hazard is mounting daily. For just one example, a study in Science that haunts me is one suggesting a function of sleep is to flush metabolic byproducts and toxins from the brain—including the beta-amyloid plaques that accumulate in Alzheimer’s disease. Sleep-deprived people are at higher risk of diabetes, obesity, depression, and cardiovascular disease.

I put the question of resident health concerns to the ACGME directly. They answered less so: “The ACGME is committed to addressing physician well-being and recognizes that many factors contribute to well-being, beyond hours worked.” (Though what we’re talking about is hours worked.) The group went on to detail ways that residents will have support if they are feeling exhausted or burned out, like provisions for transitioning the care of patients to other doctors when a resident is fatigued or ill; and the requirement that hospitals “must provide adequate sleep facilities and safe transportation options for residents who may be fatigued.”

It’s delicate language—suggesting that a person may occasionally be fatigued after running around a hospital for 28 hours. And the problem for me was almost never that there wasn’t a bed, but that if I had chosen to use it, patients would’ve gone neglected. If I said I was too tired, one of my already beleaguered colleagues would bear that burden.

Sweeping changes to this complex system are clearly impractical; inpatient hospital work is a tapestry of personnel dynamics, patients in need 24-7, multidisciplinary teams to be coordinated and bottom lines to be met. Doctors today see ever more patients in ever shorter visits and spend ever more time on paperwork.

In that light, the less discussed factor in work-hour debates is that residents are a cheap source of labor for hospitals, as compared to senior doctors. Over the years, representatives from the ACGME and Association of American Medical Colleges have been emphatic that hospitals do not profit from the labor of residents. This has been the long-accepted idea, though it has not born out in independent analyses or basic economic arguments.

Even though residents are licensed M.D.’s often working 80-hour weeks—often on the least desirable tasks at the least desirable hours—resident physicians make $50,000 to $65,000. On a per-hour basis, that breaks down to less than most ancillary staff at the hospital. Immediately upon completing the residency program, though, the same doctors command a salary of four, six, or eight times as much.

In either case, the workflow in many hospitals would crumble if residents instantly started working 10-hour days and rarely overnight. A 16-hour maximum, though, represented incremental movement toward a change in culture. The medical profession is rife with stubborn adherence to tradition, but it is an especially dramatic failure of imagination to think that a well-slept physician workforce is simply precluded by the nature of the work. It is clearly true that shift changes are a source of miscommunication and error, but it’s deeply unimaginative to consider that the solution is to keep people working beyond the point that neurobiology tells us our systems can function well, even adequately.

The doctor will skype you now

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Technological advancements over the past century have granted clinicians the opportunity to incorporate the use of telemedicine in their practice. But what are the pros and cons of this new technology? Two surgical oncologists from the University of Sheffield in South Yorkshire, UK, conducted a review of ten studies – all of which presenting highly favorable results within surgical subspecialties. The listed advantages of telemedicine include:

  • Improved access and convenience, not just for patients living in rural areas, but also for regional centers who can now consult with tertiary units for specialist input
  • The lack of travel necessary means less costs for patients and less loss of time off needed for consultation
  • There is some evidence that telemedicine significantly reduces unplanned clinic attendance
  • Reduced staffing requirements might mean that telemedicine could allow for more efficient workforce planning to deliver remote clinical consultations

However, there of course concerns to consider. These include:

  • Technological barriers, which could particularly prohibit smaller institutions, rural and/or older patients from using these services
  • Successful consultations depend on the quality of connection and bandwidth available, the development of adequate infrastructure is a must
  • The lack of direct contact, which both patients and doctors cite as a big concern. It seems clear that while video telemedicine cannot replace the diagnostic capabilities of physical examination, there is also evidence to suggest that most clinicians using these systems are highly satisfied with the quality of consultations
  • Medicolegal issues need to be sorted out regarding remuneration, insurance, and prescribing of telemedicine consultations, as well as electronic security and patient privacy.

The authors think that in time, the advantages will outweigh the disadvantages. The change is already happening: Telemedicine will fundamentally alter the interaction between physician and patient and, they hope, transform the quality of care delivered to patients for the better.

When Being a Doctor Is Similar to Running

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Joy and pain are both part of the equation, says Jordan Grumet, MD

 Sometimes before I go on a run, I take the laces of my jogging shoes and tie them together in a knot. I wear the pair around my neck with each shoe falling to opposite sides. The heels clunk against my chest as I make my last minute rounds. It’s as if running is my job and the shoes are the instrument I use to perform that job. Eventually, I slip them off my neck, and onto my soul. It’s time to go running.

Today started in much the usual fashion. The first few blocks were rocky, but eventually, I established a pace. A mile in, I turned the corner, and I was on my beloved lakeside path. I could still feel the thumping on my chest. At first, I couldn’t help but smile. I was on the right path, the right journey. I passed fellow runners, and we shared a knowing glance. We were brothers and sisters, comrades in a common goal.

 As the miles continued, my joy began to fade. My feet burned, and my knees started to buckle. The sun battered my brow occasionally providing warmth, but often scalding. I passed my normal turning point but kept going. The pain faded and was replaced by a certain fatigue, a weariness. I was still uncomfortable, but I no longer cared.

Suddenly, I tripped on the shoelaces as if they were still tied together, and collapsed onto the pavement. For a moment, a dagger lanced through my hands and wrists before abating. The blood now dripped from my extremities.

But I was miles from the beginning; I couldn’t just stop.

My pace home was slow and methodical. The miles clicked by as my head hung down, no longer entranced by the joy of the lakeside path. I hid my eyes from my fellow joggers as they whisked by. I was embarrassed by my all too visible scars. My all too apparent pain.

I returned to the entrance of my house haggard and beat down. I no longer remembered neither the joy nor the pain of the journey I had just taken. Instead, I was empty.

 Had I taken the wrong path?

I climbed the steps and pushed the key into the lock. I sat on the bench in the mud room and took off the blood spattered shoes. For a moment, I went to tie the laces in a knot again and throw them around my neck.

Muscle memory.

Instead, I chucked the miserable pair unattached into the hallway closet.

Maybe it is time to stop running.

Doctors are quietly opting out of medicine

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Dr. Ryan Flesher was working his usual shift in the emergency eepartment that night in July of 2006.  The hospital was short-staffed, per usual, and patients continued streaming through the revolving doors.  Neither the people at the front desk nor the nurses saw Dr. Flesher slip quietly down the hall that night.

The following is a true story that occurred well before healthcare moved to its national platform, leaving uncertainty in its wake. The main character’s name could be substituted by half of the physicians across the country. But, for now, we will start with Ryan Flesher, MD.

His chapter one

The youngest of 6 in Huntington, West Virginia, Ryan’s Dad was a foreman at a truck body shop, and his Mom was a homemaker. Ryan was an above average student with a mind for science and a simple desire to help people. Compassion, according to any study ever conducted, is the number one reason why individuals choose careers in medicine.

What happens to these young, altruistic people who enter the field of medicine? We toss them into medical schools and residency programs, many of which are run like medieval tournaments designed to undermine the confidence of each player and destroy all sense of collegiality. Med students and residents most commonly describe their medical training as follows: “They beat the good stuff out of us”.

In a recent commencement speech at Stanford University, Atul Gawande, MD, MPH acknowledges, “There is no industry in the world with 13,600 different service lines to deliver.  It should be no wonder that you have not mastered the understanding of them all. No one ever will.”  But the world will expect of them nothing short of mastery and perfection.

Free falling

Newly licensed to practice medicine, Dr. Ryan Flesher joins his fellow colleagues as they step onto a conveyor belt that is heading straight for a cliff. Whoops. Nobody built a fence.

Stumbling to their feet, young doctors often find themselves confronted by administrative and regulatory officials armed with clipboards. New hires come to discover that one’s training in the art of medicine and bedside manner pales in comparison to one’s business acumen. The plans they had of sacred time they would spend building relationships and caring for patients. Imagery, dreams.

When one has sacrificed 14 years of one’s life in pursuit of a concept, not a reality…there seems no turning back. Resigned, Dr. Flesher joins the legion of other physicians in white coats with bulls eyes emblazoned across their backs.

A sense of disillusionment began to slowly curl itself around him and creep upward like a deadly vine.

Imperfect storm

Cognitive dissonance is a dangerous mix of chemicals when buried. That’s just what happened to Dr. Ryan Flesher on that infamous night in the small, tiled room.

Years of forbidden emotions erupt and spill across the floor like shards of glass. “I hate being a doctor,” he says to himself.   These are words no physician ever wants to say out loud.  Panic surges through him; “What will I do? What will my family say? Have I wasted my life? Is there something wrong with me? Is there something wrong with medicine? Do I Leave? Stay? Fight? Go?”

The exodus

Doctors are quietly opting out of medicine, or they are leaving this life altogether. According to Medscape Medical News, as recently as March 2010, “The United States loses the equivalent of at least one entire medical school class (approximately 400 physicians) each year to suicide”.  In other words: one, sometimes two, a day.

People often respond to reports of physician dissatisfaction by saying, “Well, I don’t like my job either.” But the role of a physician cannot be paralleled by any other. They have the least amount of rights of any profession; they must sacrifice approximately 14 years of their lives to the study and practice of medicine and they are held to a standard of perfection that simply does not exist here on earth.

Cradle and all

One of the most dangerous things people can do is to question the integrity of honorable human beings. The repercussions can be prolific. Physicians, in general, are good people.  They are daughters, fathers, sons, and mothers.  Loathe to the notion of pity, they simply want what is fair and just.

An entire healthcare industry profits off the backs of doctors and patients. Without them, there is no industry. Problem is this unsettling shift in the foundation of medicine has caused cracks to form. How is it nobody thought to look at the structural problems before they built the skyscraper?

Our children, loved ones, all of us; we are falling through those cracks. And when the bough breaks … who will be left to take care of us?

Patient’s View: 10 Things I’d Like to Tell My Doctor, But Don’t

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In response to the slideshow MedPage Today posted Monday, “10 Things Doctors Wish They Could Tell Their Patients, But Don’t,” we received the following reply from a patient’s perspective. The author is Marilyn Geiger, of Greenwich, Conn., who holds a law degree from Columbia University but describes herself primarily as a mother and grandmother with “no experience in medicine other than as a patient.”

1. My time is valuable, too. Stop overbooking, and at least give me the courtesy of an apology when you are running late.

2. If you find that patients are being rude to your office staff, try sending in a shill patient so that you can see how staff interacts with patients when you’re out of earshot.

3. Please don’t make me call the office three times before you call in a refill for that antihypertensive/proton pump inhibitor/levothyroxine that I’ve been on for years.

4. Your nurse has long fingernails, and I wonder if her hands are really clean.

5. I know electronic health records are the new thing, but it would be nice if you looked up from your computer once or twice while I am describing my symptoms.

6. Walk the talk. Don’t tell me to lose weight when you can barely button your white coat these days. Don’t you think I notice?

7. Yes, I know the drug rep is pretty, but it’s not fair to make me wait so that you can enjoy her attentions for a while longer.

8. If the phone menu at your office requires that I press more than two buttons to get where I need to be, it should be redesigned.

9. I am human. I am scared. What is routine to you is earth-shattering to me. I know that’s hard to understand after all your years in practice, but it’s true.

10. I appreciate you. If I didn’t, I would never make a second appointment.

4 Times You Should Question Your Doctor

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4 Times You Should Question Your Doctor

Doctors are some of the most educated and celebrated people in modern society, and for good reason. They go to school for decades to learn the complexities of the human body and are able to heal the sick.

But even though they are experts on medicine, you, the patient, are the expert on… you. You know your body best – what’s normal and what’s not.

In addition, physicians are usually not experts on the cost of medicine. Medical billing and insurance are fields in and of themselves that require a different set of skills.

So if a visit to your doctor leaves you uneasy, ask for an explanation. Here are four valid reasons to question your doctor:

1. You’re told you need a costly imaging exam.

Imaging exams are among the most overused procedures in medicine, and the U.S. Food and Drug Administration estimates that 30 to 50 percent of them are not medically necessary. The overuse of these exams has consequences you might want to consider before agreeing to an X-ray, MRI or other imaging procedure.

First, there’s the risk of radiation exposure. While many imaging exams are one-time diagnostics, the overuse of ionizing radiation has nonetheless been called into question by the FDA. This type of radiation is used in CT scans and fluoroscopy, but not ultrasounds or MRIs, and there is reason to believe it may elevate cancer risk.

Even if the imaging exam in question isn’t one of these high-risk types, these procedures are almost always expensive. Base charges start around $200 for ultrasounds at the least expensive hospitals in the country, but run about $1,000 on average, according to 2013 Medicare data. Those prices are before insurance, but you’ll still be responsible for most of the cost if you haven’t yet met your deductible.

The third consequence of unnecessary exams is the unneeded exposure to the medical industry. The more procedures you undergo, the higher the chance for error. Errors include costly billing or coding mistakes, but they also include medication errors and accidental injuries, which can happen for even routine imaging exams. In 2009, there were 170,000 reported medical errors in the U.S., and nearly a third of all injuries each year are due to medical error.

You can find out whether you need an imaging exam that might cost you more than just a thousand bucks. First, ask your doctor if the test is absolutely necessary. If she gives you an unclear answer, ask if there are any alternative tests that might work. Get a second opinion if you’re still unsure.

2. You’re given a life-altering diagnosis.

While getting a second opinion on a diagnosis rarely results in a different opinion, you should always obtain one if you’re skeptical. The chances that a second doctor will disagree with your original doctor hover around 1 to 5 percent. Even so, a second opinion on a costly surgery or medication regimen often gives patients the confidence they need to proceed. This is especially important for diseases such as cancer and autoimmune disorders, which can be painful and costly to treat.

Second opinions are always in the patient’s best interest, so if your doctor is discouraging one, he or she may have ulterior motives. Even though they are in the minority, many doctors get kickbacks from drug companies or medical imaging facilities to refer patients. If a second doctor says you don’t need any of the items your regular physician suggests, consider a new regular physician.

Ideally, your doctor will provide you with referrals to specialists in his field, and most doctors are happy to do this. Like other professionals, they often talk to colleagues to get a better scope of their work.

When doctors have a patient in common, it benefits all parties for them to discuss your health. Two heads are better than one, as the saying goes. If your original doctor was incorrect about your diagnosis, the second can provide insight as to why, so the mistake won’t be repeated. Like many fields, practicing medicine requires continual learning to be done well, and great doctors know this.

3. You’re assured of something outside their control – like cost.

As smart as they are, most doctors know little of the ins and outs of insurance policies. They have high-stress, important jobs that often leave them with little down time. That’s all the more reason to take with a grain of salt anything your doctor says to assure you that you’ll be covered by health insurance.

Surveys evaluating physicians’ understanding of treatment costs and insurance show they would like to understand more. Even so, the current knowledge of costs of care and health insurance is low among physicians. Less than a quarter can guess their hospitals’ charge for 15 common procedures within 25 percent of the true price.

If you’re assured that you’ll be able to afford something, or cost is downplayed, you should consider the possibility that your doctor is disconnected from health costs. Whenever possible, double-check prices and insurance coverage with billing personnel before agreeing to a test or procedure. It’s their job to know costs and health insurance information, not your physician’s.

4. You’re uncomfortable.

Open communication and confidence are key to the doctor-patient relationship, so question anything that undermines that rapport. Great doctors listen to concerns, ask enough questions to solve patient problems and are honest and sincere. Research has shown that when doctors are attentive and empathetic, outcomes are better for their patients.

A doctor who’s rude, doesn’t listen or makes you uncomfortable isn’t on your side. Most doctors care about their patients and want to do their job well. If your doctor ever makes you feel uncomfortable, it may be time to find a new one.

DIAGNOSE AN EAR INFECTION WITH A SMARTPHONE ACCESSORY

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Is there anything that’s worse than having a child who might be suffering from an ear infection? (Other, of course, than being said child.) A new device hopes to make those cases easier to diagnose by taking advantage of the powers of your smartphone.

Like the Peek Portable Eye Exam Kit, CellScope’s Oto Home is a medical device that attaches to your smartphone; in this case, it’s an otoscope—the black conical doohickey that doctors use to look at your ear. While the Oto Home can’t itself tell you whether or not someone is suffering from an ear infection, its companion app lets you take a video of the ear and send it to a medical professional, who can then hopefully diagnose the condition—and potentially even prescribe treatment.

That provides a number of benefits, such as not having to tote a crying child to the doctor’s office where you wait interminably for your appointment. Instead, CellScope aims to have a response for you within two hours, which is probably less time than it would take to drive to the doctor’s office, go through the appointment, and drive back.

Oto Home

CellScope

The Oto Home itself costs $79, but each remote consultation costs $49 (when you buy the Oto Home, you get your first consultation for free). There’s also a $299 professional version aimed at clinicians that enables the device to be used as apneumatic otoscope, which lets doctors judge how the ear responds to changes in pressure. It also comes with HIPAA-compliant web storage, PDF exports for exams, and more. Right now, the device is only available for pre-order in California, and its included case is only compatible with the iPhone 5 and 5s, but more states and device compatibility are on the way.

The smartphone is proving to be a huge platform for medical devices. As with the Peek, equipment that used to cost hundreds or thousands of dollars can now be had for a fraction of that cost, in a form that is easy to transport, and in a package that also makes it easy for remote medicine. Not only does that potentially enable diagnoses without even leaving home, but it also brings quality medical care to places that a doctor may not be able to reach easily.

Really, the only downside is not getting free lollipops from the doctor’s office—but we could probably all stand to cut back on the sugar, too.

$1 million mistake: Becoming a doctor.

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 If you are brilliant, ambitious and gifted in science, you may consider becoming a doctor. If so, think twice. According to a new survey by personal finance site NerdWallet, most doctors are dissatisfied with the job, and less than half would choose a career in medicine if they were able to do it all over again.

There are many reasons for the dissatisfaction, said Christina Lamontagne, vice president of health at NerdWallet. Most doctors enter the field thinking they’ll be able to spend most of their time healing the sick. Yet the paperwork burden on doctors has become crushing, and could become even more complicated under the Affordable Care Act.

“Administrative tasks account for nearly one-quarter of a doctor’s day,” Lamontagne said. “With additional liability concerns and more layers in health care, we can understand the drain this takes.”

Doctor: Patients should take active role in care

Worse, the cost of becoming a doctor has soared, with higher education expenses leaving the average newly minted physician with $166,750 in medical school debt, while average salaries are declining. Nearly one-third of doctors — 28 percent – saw a cut in pay last year, according to NerdWallet’s research.

To be sure, pay is still high, with of six-figure positions in the country, according to government data. But it also takes between 11 and 14 years of higher education to become a physician. That means the typical doctor doesn’t earn a full-time salary until 10 years after the typical college graduate starts making money.

That lost decade of work costs a cool half-million dollars, if you assume this individual could have earned just $50,000 annually, and the typical medical school candidate is smart and successful enough to earn considerably more. Add in the time and cost it takes to pay off medical school debt and a dissatisfied physician may well consider pursuing medicine a $1 million mistake. (This assumes the average $166,750 medical school debt  takes 30 years to repay at 7.5 percent interest — a total cost of $419,738.)

Moreover, primary care physicians — those who go into pediatrics, family and internal medicine — earn barely more than the amount they accumulated in medical school debt, between $173,000 and $185,000, according to the study that looked at data from George Washington University’s School of Public Health, the American Association of Medical Colleges and Medscape.

The least satisfied physicians are those who go into internal medicine, according to the study. On average, these doctors see two patients every hour while spending 23 percent of their time on paperwork. They work an average of 54 hours per week, take home about $185,000 annually, and a fifth have seen a decrease in pay. Just 19 percent would choose the same specialty, and only one-third would choose a medical career if they had to do it over.

“The frustrations that patients have about not getting enough time with their doctor is mirrored by the frustration their doctors have with not having enough time to spend with their patients,” LaMontagne said.

  • The best paid doctors are orthopedic surgeons, who take home an average of $405,000 annually. The most satisfied appear to be neurologists, who earn an average of $216,000, while working an average of 55 hours per week. Sixty-percent would choose the same specialty, and 53 percent would go into medicine again. Oncologists — the doctors who treat cancer patients — are also generally satisfied with medicine and their jobs, with 62 percent saying that they would go into medicine and 57 percent reporting that they would choose oncology as a specialty.

Radiologists are the physicians most likely to have suffered a pay cut in the past year, with 42 percent reporting a decline in salary. However, they’re also among the best-paid doctors, earning an average of $349,000. More than half would both choose to be doctors again and choose the same specialty.

The doctors who work the longest hours are cardiologists, who report being on the job 60 hours per week. Some 54 percent would choose the same medical specialty, but only 44 percent would go into medicine again if they did it over. The average cardiologist earns $357,000 annually, though 39 percent have seen a cut in pay in the past year.

Those least likely to have suffered a pay cut are emergency doctors, who earn an average of $270,000 and work an average of 46 hours per week. Just 19 percent of emergency doctors suffered a cut last year, but only 41 percent would go into medicine or emergency medical care again.

Across all specialties, physicians see roughly 13 patients per day, work 52 hours per week and earn an average of $270,000. However, family and emergency doctors see nearly 75 percent more patients than anesthesiologists.