Tuesday, January 12, 2010
I think back to my childhood. And how I looked up to my father...the physician. How he died when I was so young. His last gift to me was his profession. How an eight year old somehow made a decision about what he would do with his life. It didn't matter that I had a learning disability.
My thoughts were pure. My intentions the best. Money was the farthest thing from my mind. I studied hard. Tackling the first years of medical school with vigor. Scoring among the highest in my class. Only to be whacked by the reality of my clinicals. Abused by some of my teachers, undercut by fellow students.
I entered residency a little less naive but no less excited. I married. I matured. I held my patients well being in my hands as best as I could. The weight of responsibility sometimes crushed me. There was that night in the ICU when the elderly man in respiratory distress crashed. Where I botched the code. And then had to tell his family over the phone. And the guilt ate my insides out. And I clammed up. The night I dropped my applications to fellowship.
I became cold...but no less dedicated. I lost my self in a protectionalist shell. I replaced joy with calm. I replaced tenderness with cold clinical aassessments. And I became the doctor that I despised. Maybe not to my patients or to my colleagues but I knew the difference. I felt so much rage against the system...against the medical group that I worked for....against the government who wouldn't let me practice the way I wanted to....and sometimes against the patients themselves.
But then my first child was born. And I started to blog. And my heart opened up. I learned how to feel with my patients. How to cry with them. I took their stories home with me each night. And my skills grew. I learned how to read into not only what a patient said but how they said things. I watched the way they walked into the exam room. The way they held their head.
I became a better physician. I learned how to help my patients live with disease....I helped them learn how to die with dignity. I started to catch things that others didn't. Things I had only read about...the guy who was traveling and got erhlichia, the lupus patient with csf rhinorhea who got methemoglobinemia from dapsone,the diffuse lewy body disease missed by the neurologist, the conns syndrome, and the young guy with acromegaly.
And I learned how to be economically as well as medically efficient. Only consulting specialists when absolutely necessary, eschewing antibiotics for watchful waiting, managing patients in the office or nursing home when my colleagues would have put them in the hospital, billing the same yearly totals as my piers but seeing hundreds more patients in the same time period.
I make a nice living. Much better then I ever thought I would. My office is full. The nursing homes are always calling. I see my own patients in the hospital. I am efficient but thorough. I may only spend 10 minutes in the room with the ninety year old with chf,diabetes,and copd. but I also spend 10 minutes reviewing her chart. And 15 minutes on two separate occasions with her on the phone. And 30 minutes calling her cardiologist discussing my plan for her.
But things are changing in medicine. Overwhelmed by a system that costs too much the government is forced to make changes. And the debate roles on about who is at fault. Is it the insurance industry...pharma.....or doctors. We all know that the doctors pen is the most expensive technology in health care.
We all say that primary care doctors are not paid enough. But in the same breath we say that they inefficiently manage their patients, order to many tests, consult too many specialists, and miss to many diagnosis. We talk about quality as if it is something that anyone really knows how to measure.
And I see such change coming. Medical homes...pay for performance....bundled payments....employed physicians.....the endless jargon of health care reform. And my anxiety grows. For those who practice ineffectively some of these government intrusions will undoubtedly bring them in line. But for some of us....those who have prided themselves on cost effective, efficient care...these changes will just slow us down. They will make it harder to get reimbursed at our current level. They will produce more silly administrative hoops to jump through. More useless pain. Eventually many of us will leave. Why not work for an insurance or drug company. Even if we are happier practicing...at least our type of medicine.
It makes me sad. And makes me think....the reformers...the government....I wish they would just leave me alone.
Posted by Jordan Grumet at 5:39 PM