Monday, January 16, 2017

Thrive

It was only later that I discovered the underlying reasons for the move.  My parents purchased a home in neighboring Wilmette.  The contract was signed and a date was set.  Being in second grade, I doubt I worried about the details.  Maybe I was concerned about enrolling in a new school, I don't remember.  It was nothing in comparison to the tumult I would feel when we relocated after the wedding, before high school.

When my dad died, I assume the contract was nullified.  The overwhelming upheaval to our lives was so great, that a seven year old boy couldn't possibly comprehend the complexity of adult decision making.  We were going to move and then we weren't.  My dad was with us one day, and then he wasn't.

And my life was afloat in uncertainty.  Stalwart in the idea of becoming a physician like my father, I struggled with a learning disability profound enough to keep me well below the level of my peers.  I sat in homeroom coloring while my classmates read from textbooks. I had an army of school provided tutors as well as a private learning specialist.  The picture would have been fairly bleak if I had been old enough to recognize.

But children can be unfalteringly ignorant toward melancholy.  Their unfettered engines continue to run.  They continue to run free.

My two memories left from that year color almost all that I am. In the living room surrounded by family, as my mother whispered in my ear that dad was gone.  And months later, the day my teacher placed a textbook in front of my face and I read.  Surprised, she place another.  A slightly more complex.  And I read.  Then another.  And another.  The children looked up in awe as a pile of textbooks formed on the side of my desk.

My reading and writing improved so much, it was decided that I indeed could matriculate to third grade. Which was incidentally the reason my parents had planned to move in the first place.  They were going to hold me back, and felt it would be less devastating if I transferred to a school where none of the kids knew me.

Years later, my mom would remarry and move us into the same district that I narrowly missed in grade school.

And I would thrive.

Saturday, January 14, 2017

Identification and Intimacy

To say that there is no fear in the examining room is an inaccuracy.  I'm not only talking patients here.  Physicians may harbor just as much worry and discontent .  There are the old standbys of course.  The swat team of malpractice attorneys lounging in the waiting room ready to pounce.  Or the old demon of misdiagnosis and the consequences that may follow.

Few of us talk of that sinking feeling that comes with the realization that in the course of doing our jobs, we invite physical danger.  During medical school, I remember a psychiatric patient barricaded one of my peers in an interview room.  The standoff lasted forty five minutes until she was able to escape unscathed.  Physically at least.

I can no longer count the various times I have treated criminals, psychotics, or just plain agitated dementia patients who were willing to take a swing at whomever was in reach.  For the most part, these interactions have melted away quietly leaving me with little lasting effects.

My escape from the traditional examining room has also brought a new set of challenges.  Knowing a patient had a loaded gun a few feet away was somewhat jarring.  Or traveling to a not so safe neighborhood during erratic hours.  One becomes aware of ones surroundings more quickly. There are countless dangers that won't bow to our flowing doctorly lab coats.    

But by far, our biggest unspoken and often unrealized fear, is that of identification.  How does one break the horrifying news to a dying young person and not look in the mirror and see a similar countenance?  How do we not envision our spouses, our parents, and our children in every hapless medical misadventure that we are a party to?

The answer is that we don't,  We use our walls to create a sense of otherness.  We shield ourselves to such an extent that it my twenty year career, I have rarely had these conversations with colleagues.  

And as I get older, I wonder if we should.  There is a certain intimacy in identification which has been lost on those that hide behind the stethoscope.

We give ourselves a pass.

Wednesday, January 11, 2017

My Advice to You

It will start as a minor curiosity.  Maybe a student will seem slightly too close to the resident on your team.  When the grades are posted you'll wonder why you didn't get honors but he did.  You might wallow for a few days.  Make an off-handed comment to your fellow students.  Then you'll let it go, and move on.  Or so you think.  Until during surgery when the scrub nurse rips into you to make a point to the rest of your peers.  And then the surgeon does the same to her in the operating room.  

There will be other times.  During residency you will roll your eyes when you realize your co-intern is sick again, and you're up for all the admissions.  You will curse the medical student who created the cockeyed explanation and scared the heck out of the frightened social admit in room 5.  You might not yell.  You might not lose your cool.  But rage will boil over from time to time.  You may let it loose on the radiology tech who is refusing to get up in the middle of the night and do your stat study.  

Your path will continue even after you are done with training.  There will always be plenty of culprits.  The secretary who double booked your over packed schedule.  The prior authorization phone tree that will waste the precious moments you could be spending with your children.  The paranoid anxious patient who will put it off all day, and show up to the emergency room at midnight and awake you from a deep sleep.  You will argue incessantly with the emergency room attending who will refuse to send him home and insists on observing for cardiac ischemia.

And you will find yourself yelling uncontrollably at the cowering patient who pulled you out of the examining room with the young guy with melanoma who was finally willing to talk about hospice, because she forgot to ask a question thirty minutes ago during her appointment.

When you look into her tear soaked eyes, a hard reality will come upon you.  You are angry.  You have been for years.  Rage is constantly simmering below the surface scalding you and those you interact with.

You have truly become a doctor.

My advice is simple.  Forgive yourself.  Remember that that medical student who undercut you was wallowing in much the same way as you.  The surgical scrub nurse had felt a hundred times the abuse from the surgeon who was still scarred from his own training.  Your fellow resident was actually sick and spent all night puking in the bathroom.  The radiology tech hadn't slept well for weeks.  The secretary had been cursed out by the patient for not making room in your schedule.  The anxious patient was suffering, and the ER attending was trying to be compassionate.

And yes, the young melanoma guy is dying and no one is dealing with it.

Then shrug your shoulders, exhale, and decide to turn the anger into love and understanding.

Life is much better that way.

Monday, January 9, 2017

The Guidelineification of American Medicine

His voice was gruff and his expression surly.

I don't want any more medications.

His face was indented by deep clefts, remnants of eight decades of  life hard lived.  His tone was commanding and certain.  I knew that he was fond of me, but I could feel his patience slipping.  He neither asked about nor accepted his diagnosis of heart failure.   I could tell him till I was blue (or he was for that matter) in the face that his low ejection fraction portended a poor prognosis, and national guidelines suggested both a beta blocker and defibrillator placement.

He wouldn't budge.  And before the age of electronic medical records, evidence based medicine, and quality scores, no one really cared.  Before we would have taken the patient's wishes into account.  Noted that he couldn't afford the new med, nor was particularly compliant with his other medications.  Considered that his wife had died a few years back, and he had no interest in extending his life.  Weighed the positives and negatives from the patients perspective, and come to a tailored decision for this particular human being.

But now the guidelineification of American medicine has turned this proud and aged skill into a humdrum maze of algorithms.

Algorithms that are more expert opinion and less evidence based. Algorithms that rely on evidence collected from typical white male patients with isolated disease processes and may not be generalizable.  Algorithms that will change often and probably contradict themselves in the decades to come.

The true art of medicine, expertly meshing the known with the unknown.  Factoring in human variability and preference to develop a unique plan.  Has been lost.  Ridiculed. Chewed and spit into the trash.

We pray to the ever eroding alter of longevity.  Even as our patients have abandoned such false deities.

They want quality of life.  They want control over their own decisions.  They want to go with their gut sometimes.

And I think we should support them.

Saturday, January 7, 2017

A Doctors Story

Many years ago, three doctors formed an internal medicine practice and were proud of the thousands of patients they accumulated.  They were fine physicians and very dedicated to the masses who walked through their clinic doors.  They saw patients in the office, rounded at two hospitals, and visited a number of nursing homes.  This was truly a full service practice.

Around 2005, Dr. A was starting to fatigue.  He was well into his sixties and did not like the direction medicine was going.  The hours were too strenuous, the documentation requirements were getting increasingly complicated, and he saw the writing on the wall.  Regulation was coming and the results would be devastating.  So he decided to retire.

Luckily, Dr. A's patients (around 5000 at the time) could be seen by the two younger physicians in the practice (Dr. B and Dr. C) after he left.  They both, by now, had thousands of patients of their own, but were happy for the extra work.  A final retirement date was set, and Dr. A officially left the practice in 2006.

Unfortunately, without Dr. A's influence, Dr. B and Dr. C had a series of disagreements and decided to break off the relationship.  Half the practices ten thousand patients stayed with Dr. B, while the other half moved locations to join with Dr. C.

Dr. B needed extra help handling all those patients and hired Dr. D.  Dr. C needed extra help handling all those patients and in 2007 hired Dr. E.  Both practices thrived.  Their client rosters swelled even as they faced the continuing assault of governmental regulation.  Thousands of dollars were spent acquiring and utilizing electronic medical records.  Countless hours were wasted filling out forms and on administrative phone calls.

Around 2013 Dr. E realized that he was spending more and more time on paperwork, and less and less time on patient care.  His patients were upset, his personal life was suffering, and most importantly, he was no longer proud of the quality of medicine he was practicing.

So in 2013 Dr. E made a momentous decision.  He left his 2500 patient practice and started a home based concierge model consisting of only 100 of his former patients.  The rest stayed with Dr. C.  Dr. E also continued to do nursing home work taking care of other physicians patients, as well as started an administrative role with a local hospice.  And he thrived.

Dr. C continued to manage his own patients as well as all those extra that were no longer under Dr. E. But by 2015 he was having trouble maintaining a reasonable lifestyle, and his economic fortunes had worsened.  Feeling forced, Dr. C  also converted his practice to a concierge model and his patient panel shrunk from over 5000 to less than 500.   And he thrived.

Now we must not forget Dr. B and D. They made a successful run at private practice and hired various other physicians and nurse practitioners over the years.  The ranks of their patient population swelled.  By 2015, however, they began to feel the futility of the current medical system.  Thus Dr. B and Dr. D also eventually went concierge, and limited their practices to 500 patients each. And they thrived.

So if we do the math:

Dr. A had 5000 patients and retired.  He no longer is involved with patient care.

Dr. B moved to a concierge practice and narrowed his patient population from 5000 to 500.

Dr. C moved to a concierge practice and narrowed his patient population from 5000 to 500.

Dr. D moved to a concierge practice and narrowed his patient population from 2500 to 500.

Dr. E moved to a home based concierge practice and narrowed his patient population from 2500 to 100.

Now before you get in a huff, of course there is some overlap here.

Most of the abandoned patients joined the prominent medical group in the area and still have doctors, though often have to wait months for simple appointments.  Many of them barely know their physicians and are seen by nurse practitioners.  None of them have the benefit of having their own doctors in the hospital or nursing home.

You might think I am being hyperbolic.

You might think this story is an exaggeration or fairy tale.

But I'm here to tell you it's not.  I know.

Because I am Dr. E.

Thursday, January 5, 2017

Just Like She Said

If Bob had realized that these were his mother's last words, he might have stopped what he was doing and stood by her side.  But her foley catheter was leaking again and the sheets were a mess.  Besides, he didn't want to wake Rhonda in the adjacent bedroom.  She had just gotten off third shift and needed to rest before taking over in a few hours.

Bob felt guilty about losing his job, but given his mother's current state, he couldn't justify taking another gig out of town.  Because the Medicare days at the nursing facility had finally run out, his aging mom was forced back home.  At first she was able to smile and even talk occasionally, but that was mostly gone.  She mumbled from time to time.  Nonsensical mumbo-jumbo. Or stared blankly.

Bob listened to his mother's distorted vocalizations as he undid her flimsy coverings  He had debated whether to change the diaper or remove the bed sheets first, and settled on the diaper.  The morning news blared on a TV which had been optimistically moved into the room before her arrival.  She no longer could focus on the screen, but at least there was background noise.

Bob's hands moved quick and efficiently.  He sometimes wondered during these long days if he should have become a nursing assistant.  He was strong and able.  He had the right constitution and didn't get queasy when dealing with the indelicacies of the human body.

His mom exhaled and then did something she hadn't done in months. She spoke.

Bob, Bob quit messing with those sheets.  I'm dying.

Of course Bob didn't think.  She has been talking out of her mind ever since leaving the hospital.  He secured the diaper and pulled up the sheets.  It was then he noticed that she wasn't breathing.  Her chest was completely still.  He called out for Rhonda and she rushed into the room blurry-eyed.  They stared at each other for a moment, not knowing what to do.  Then he called 911.

Bob new the chest compressions were futile, but allowed them for a short time before asking the paramedics to stop.

His mother was gone.

Just like she said.  

Tuesday, January 3, 2017

Evolution

You won't at first.  But then you will.

It will start innocently.  Probably even before medical school.  You will have a morbid curiosity about passing ambulances and motor vehicle accidents.  Your original empathy for the victim will disappear when you begin to think of them as patients. Test cases.

The commodification accelerates during the early years of medical school.  Anatomy, pathology, and physiology provide you a vocabulary to replace human pain and suffering.  In gross anatomy you violate the viscera even as you hear your fellow students snigger in the background.  You may not take part in their school-boy antics, but it loosens in you a certain callousness that you were previously cautious to recognize.

During the clinical years you will learn to build walls with the most rudimentary artifacts.  Your first death.  A mistake.  Your resident standing over blaming you for the post op infection and eventual demise of a beloved patient. Your hands will scramble as you crouch amongst the linoleum of some hidden dark corner of the hospital ward, collecting dust and discarded gum.  Your eyes no longer seeing, your heart trying desperately not to feel.

Residency is when you will become the master builder. Unslept nights.  Missed meals.  Standing on the front line wading through the intolerable excrement and blood of actual healthcare.  You will learn not to cry, not to contemplate.  To traipse from life to death wearing the same distracted grimace.  And you will yell at that poor medical school student about the post op infection for which you secretly wonder if you caused.  You now work with brick and mortar, clay and stone.  Your tower rises above and beyond, up to the sky, encircling you.  You are alone.

Your expertise will be so great by the time you are an attending physician, nothing will penetrate your ironclad barriers.  Unlike those walls, however, your heart will be porous and ooze sadness, anger, and despair.  Trapped inside that small space.  Devouring you.  And love, and family, and friends, and light, and oxygen will all be awaiting on the other side.    

A breath away, a mile apart.

If you're lucky, you'll fall to your knees to the grit and grime and start clawing with bloodied knuckles.

Brick by brick you must undo that which you have built.

That which has been built for you.