On writing about female physicians and the Grand Canyon: A Q&A

Photo by DomCarver

As a voracious reader, I particularly enjoy mystery novels featuring a female detective or medical examiner. And as physicians know so well, medical mysteries can be just as gripping, and surprising, as crimes. So I was eager to read the novel, Only Rock is Real, about a female doctor with a family practice at the Grand Canyon. I spoke recently with the book’s author, Sandra Miller, MD, who is a writer and retired family physician.

What motivated you to write novels?

I have always written poetry and essays, but crafting a novel pushes my writing to another level. The process of weaving a plot — while creating compelling and authentic characters, developing their growth and showing their stumbles — is riveting to me. The greatest compliment is when readers tell me they feel like they know my characters personally and care about them.

I’m also on a mission to promote family medicine and women physicians through fiction. I really want to encourage physicians to write, and especially to write fiction. There is little medical fiction being written currently, with the exception of the crime scene/thriller genre. I would love to see more fiction about everyday physicians and their trials and joys. And I welcome with any medical writers who want to brainstorm, share or seek feedback about their work.

How did you develop the main character, Dr. Abby Wilmore?

Like most fictional characters, Abby is partly a conglomerate of people I have known and partly made up. Every physician wants to be highly competent and strives for excellence, but there are many potholes along that path. Perfectionism and anxiety are common in doctors; finding your peace with an ever changing and critical career like medicine is no small task. I wanted to show how her confidence builds and then derails — the ups and downs of successes and errors, real or perceived, in both her professional and personal life. I wanted to show how very human physicians are.

How did you select which patient cases to include?

I tried to use a mix of cases representing a typical day: some common and some less common, some routine prevention and occasionally a very difficult case. I also wanted to include a mix of physical and mental health issues. I guess the teacher in me is always lurking, because I also selected cases where readers can learn about topics like diabetes, the morning after pill and contraception, heat injury and flu vaccines.

I keep them as realistic as I can. Sometimes you know the diagnosis immediately and other times it takes detective work. Sometimes you’re wrong because people aren’t textbooks and they don’t always follow the rules. I’ve put much effort into making all the science — medicine, geology and astronomy — as accurate as I can.

Why did you set your books in national parks?

For the last thirty years of my career in academic medicine, I helped train family medicine residents who often did a rotation at the Grand Canyon clinic. And I have friends who worked there for years. I know their stories, the human dynamics in such unusual places. Only a few national parks actually support a physician.

In addition, I have always felt a deep connection to the natural world. We’re all constructed of the same molecules; all follow the same rules of development and decay. The wonders around us are simply stunning and worth celebrating.

How do you describe your books?

I’m calling my books ‘evidence-based medical adventures.’ There is romance and a bit of a thriller plot, but the books are also filled with tons of real medicine, science and the quandaries physicians face every day. And the poetry of the night sky and the rock under our feet, not to mention the value of humor.

Are there similarities between writing and being a family physician?

I think it helps for both to know you can never know everything. And that much of life comes at us in tones of gray. Being a family physician certainly gives you a broad view of the world and the vagaries of the human mind. You need to know as much as you possibly can and you need to know what you don’t know. You keep trying your best. I think this experience helped me as a writer.

Photo by DomCarver

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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How primary care physicians can embrace population health

Photo by Guillaume
Photo by Guillaume

The Centers for Medicare & Medicaid Services’ new payment model, called the Quality Payment Program, issues a powerful challenge to primary care physicians: Improve the quality of care and save money, by focusing on population health.

What, exactly, does that mean? In part, it means that physicians will need to consider why some groups of people are healthy and why others are not — so they make care decisions that improve the health of many people.

It sounds daunting. However, it is vital, said J. Lloyd Michener, MD, professor and chair of the Duke Department of Community and Family Medicine in a recent article in Medical Economics. 

“Small practice physicians must participate in population health; it’s the future and it’s how they’re going to get paid,” Michener said. “It’s going to be really hard not to participate in this model of care.”

There are some straightforward steps physicians can take, he said, urging physicians to:

  • Build partnerships with other care providers and health-care systems
  • Ensure electronic health records, claims data systems and other software tools capture the necessary data such as patient identification and provider-performance measures
  • Look for patterns in patient care

Population health management programs use software tools to aggregate patient data and provide a comprehensive clinical picture of each patient. Physicians then use the data to track and hopefully improve clinical outcomes while lowering costs.

For example, a primary care physician could look at all of her asthma patients that aren’t getting better, identifying how often they’ve been to the emergency room and why. This might lead to the realization that her patients are mixing up their prescription medications, so she needs to educate them further about when to use a rescue inhaler verses control inhaler. Or maybe the frequent ER visitors all live near each other, and there is an environmental issue.

Michener offered words of reassurance as well:

“Primary care physicians need to know that they have the power to quickly analyze groups of patient data and intervene when necessary to make better treatment and care decisions that lower the cost of care, improve outcomes, and raise their ability to earn income under a value-based payment system. That’s an incredibly effective way to deliver care.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Most primary care doctors have favorite patients, study finds

Image by Regina Holliday
Image by Regina Holliday

As a teacher, I try to treat all my students equally but I definitely have favorites. I’m sure other teachers have favorite students too, so it makes sense to learn that physicians have favorite patients.

A team of researchers led by Joy Lee, PhD, a postdoctoral fellow at the Johns Hopkins Bloomberg School of Public Health, interviewed 25 primary care physicians who worked in clinical settings within the Johns Hopkins medical system about their favorite patients. The participating physicians were predominantly white and about evenly split between male and female.

The doctors were a bit uncomfortable with the term ‘favorite patient,’ the researchers reported in Patient Education and Counseling. It raised concerns regarding boundaries and favoritism. However, all but three of the participating physicians admitted to having favorite patients.

The goal of the study was to identify the common attributes of these physicians’ favorite patients and examine how having favorite patients impacts their physician-patient relationships.

Who were the favorites? Surprisingly, they weren’t typically the most compliant patients or the ones most similar to the doctors. Instead, they were long-term patients who spent more time with their physician while going through a major illness. So the doctors were very familiar with their favorite patients’ personalities and health histories — allowing them to provide the best care.

“For patients, these findings highlight the importance of having a usual source of care, a primary care doctor with whom they can establish a relationship,” said Lee in a recent news release. “Favorite patients might not be consistently sick, but when a crisis comes they have an existing relationship to work off of.”

Of course having favorites isn’t the same as playing favorites. The participating physicians argued that their awareness of having both favorite and challenging patients helps them prevent favoring the care of certain patients over others. They also generally like most of their patients.

“This concern demonstrates that physicians are striving to be fair and to give all their patients the best possible care,” Lee said. “We discovered that doctors really thought about their relationship with patients, which is encouraging from a patient perspective. Their thinking really humanizes the patient-physician relationship.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.