Time Waits For No One

We sold it. Katie and I. Leila's Crib.

It had been sitting. Stuffed in the corner. For the last year. After Leila got her "big girl bed" and learned how to awake in the middle of the night and wreak havoc on the household.

At first it was just laziness. We kept planning to sell but never got around to it. Then finally the add was placed on Craigslist. And the days passed and no interest. It was a beautiful crib. Pristine condition. Stylish.

So eventually we dropped the price and re listed a few times. Nothing for days....and then an email. They wanted to see it. They would be right over.

A young couple. First child. Last few months of pregnancy. They eyed the crib up and down as Leila tried to initiate conversation and Cameron ran to get his pottery. But it only took a minute to decide. They would take it.

Quickly I got the tools and started to disassemble. Leila's home. For the first two years of life. There was a flurry of activity. Unscrewing....lifting...carrying. Money was exchanged and we wished the couple well.

As they amble slowly through our front door carrying various pieces of furniture it hits me. We sold Leila's crib! My mind flashes forward to a much later time. Nursing home bound my addled brain struggling through dementia's cobwebs. I become agitated from time to time and the nursing staff hands me a baby doll. The studies show that it calms demented people to care for a pretend child.

I will hold the doll thinking that it is Leila and wander aimlessly through the nursing home. Searching for a crib to lay her down for her afternoon nap. Except that I won't find it....because I sold it. On Craigslist.

And as I stare out the window at the young pregnant women carefully placing the deconstructed crib in the back of her truck I feel great regret.

Because even now before my brain ages and becomes entombed in the plaques and tangles of senility I can't escape the basic fact:

No matter how bad I want it to....

time waits for no one.

Memories of College

I gently brushed the moisture from my brow and relaxed happily in the grassy field. The campus was barren during the summer and only a handful of students were living in the circle of dorms that surrounded the athletic center and adjacent track and soccer fields.

I just finished working out. My muscles twitching and the sweat causing my shirt sleeves to stick to my arms. As I cooled down I gently laid in the grass and allowed the sun to wash over me. Out of the corner of my eye I noticed a figure approaching.

He appeared in his forties. Wearing old tattered shorts and a t-shirt. His facial hair overgrown and unkempt in distinct contrast to his balding head. He walked without particular haste or direction. His eyes glassy. His gait unsteady.

I may have noticed the distinct odor of alcohol. Or maybe it was my preconceived notion of the homeless people in the area. The mind is highly suggestible.

Hey buddy...can you help me out?

I paused, calculating...How about something to eat?

He nodded and I beckoned him to follow. We walked down the hill to a convenience store. I only had a few dollars. We agreed on a turkey sandwich and a few drinks. I handed him the change at the register.

And then we walked back to the field and sat down. I unwrapped the turkey sandwich...giving him one half and keeping the other for myself.

We ate. Silently. Enjoying the summer day. The sweaty college student and the unkempt homeless man. We exchanged some pleasantries. Nothing too deep. Eventually he finished...thanked me...and walked off.

Years have since passed and I am a doctor. Now I spend most of my day "helping" people. But for some reason it doesn't feel quite the same.

It was like something magical happened that day.

And for a moment I felt a sense of oneness.

Humanity

Peace

I find it so hard to recapture those feelings nowadays.

No Respect I tell Ya

Sometimes I wonder....do non primary care physicians respect our opinions? Do they believe in us? Are we piers or inferiors? And in general....what do we deserve.

I was rounding in the hospital on my partners patients when I came upon Mrs. S. She was having progressive hip pain and her rheumatologist ordered and MRI which showed a joint effusion. The patient developed low grade fevers and anemia and was sent to the hospital to rule out infection.

A quick review of the labs showed the esr and crp were moderately elevated. She was anemic. Her rheumatoid factor and lupus testing were normal. The joint fluid from the hip was tapped and was not consistent with infection.

So I sat down with Mrs S and started to take a history. Upon further review she had also developed bilatteral shoulder pain. Worse in the morning upon waking. Better with activity. She had moderate fatigue.

Based on the clinical history, labs, and radiology findings, I felt the growing suspicion that this was Polymyalgia Rheumatica. So I called the rheumatologist and discussed with her my findings. I felt pretty certain. The conversation went like this...

This looks like polymyalgia....

No I doubt it...probably viral!

But what about the story doesn't fit for PMR?

It just doesn't...lets keep her off steroids and see what happens!

The patient was discharged from the hospital and later followed up with my partner and the rheumatologist.

A few weeks later I ran into her in my office. Upon asking her how she was doing I got this response:

Wonderful Dr. Rheumatology realized that instead of an infection I have Polymyalgia Rheumatica...I am doing so much better now on steroids!

No respect I tell ya....no respect.

Snapshots of Childhood

The cabin was rustic. As camp cabins go. The walls lined with bunks on both sides. I was twelve years old. At sleep away camp. It was a cold rainy day and all activities had been cancelled. The counselors were nowhere to be seen.

So a bunch of us walked over to the girls cabin. I was the last of the boys to enter through the screen door. So Jordan you really like that Natasha girl don't you. I looked up to see a mousy face peering out at me from one of the many top bunks.

I began to flush and my heart race. Natasha...of course I liked Natasha. She was the only thing I thought about the whole school year between camp sessions. The previous summer I hung out with her constantly. She was much older then I and thought of me as a little brother.

I, on the other hand, was completely smitten. I basked in her attention the year before....but this year was different. She had little use for me now. She no longer sought my attention. She was busy with the older boys. I was forgotten.

I guess I was not very good at hiding my puppy dog eyes. But to be called out in public. Standing among my friends and all those girls! I looked around the room from face to expectant face. I vacillated internally....to tell the truth and gush my feelings so publicly....or to deny, make a joke, blow it off.

I smiled sheepishly and my eyes shot to the ground. Yes...yes I like her.

Silence. And then the crowd parted and standing behind the bunk beds hidden out of sight was Natasha. I looked up and caught her beautiful eyes...all I saw was embarrassment. She sputtered a lame excuse...I was just looking at a poster in the corner...

But I barely heard the rest. I turned and left quickly through the front door. The tears brimming in my eyes...set up, I was set up!

And after all these years...

the emotion returns...

still fresh in my chest like it was yesterday.

Long...long after the memory

of those eyes

have faded.

Yesterday

I awoke around midnight to the sound of my daughter screaming. As I leapt out of bed I felt the fatigue wash over me. She was standing. In the middle of the room with her pajamas half off. She had wet herself again.

We have been potty training for the last few months. We left diapers long ago. But every few weeks....I drag myself out of bed and change her sheets and cloths. And I usually don't think twice about it.

Except now. I was finding the manual labor in the middle of the night to be more tiresome then usual. I kissed my daughter and then ambled back to the bedroom. I collapsed in bed. A wave of nausea came over me. Then a feeling of uneasiness in the pit of my stomach.

I had an inkling something was wrong.

For the next few hours I tossed and turned. Waves of mild nausea coming and going. I grasped my abdomen hoping to calm the tumult that was brewing inside.

Around 4am my wife turned to me...why don't you just go throw up already? I guess my mental moaning had become verbal. I stood up unsteadily and made my way to the bathroom. And that's when the odyssey began.

Gut wrenching...body shaking...mind numbing retching. For hours. Uncontrollable. Belly pain...nawing...the kind that won't let you sit still for a moment. Finally followed by relentless joint and muscle pain.

I spent all day in bed. I cancelled work. Cancelled thought. Cancelled any meaningful activity. Every moment became an epic battle concentrating on getting better. Each attempt at raising out of bed was met with dizzying nausea and unsteadiness.

Now this morning. After sleeping 12 hours straight. I feel better. Still tired and achy...but alive. A little warn for wear.

And I wonder. After feeling so defeated after just a measly stomach flu...what it must be like to deal with real illness. Cancer, heart disease, emphysema........the pain my patients live with every day.

Maybe this should be a gentle reminder....to be a little more kind...a little more empathic.

And oh yeah...a little more thankful.

Things Have to Change

So I evaluated the patient in the nursing home. Chest pain. She needed to go to the hospital. So I sat down at the computer and quickly wrote a progress note. The ambulance came and took her away.

An hour later. Call from the ER.

Do you have a medicine list on Mrs X? She wasn't able to tell us.

Didn't the nursing home send anything?

They said since they converted to an EMR they have no written med lists

Well I am looking at my EMR in the office and it is not up to date. A number of med changes have taken place since the last time I charted. What does your EMR say?

Oh...this is like from 2 years ago... the last time she was in the hospital!

OK...no big deal...so the ER has to call the nursing home and verbally take the med list and transfer it to the hospital EMR. I, in turn, have to update my own EMR from the hospital list. Each of these actions take time away from the doctors and nurses. Time that could be spent on patient care.

By the way...how's Mrs X's chest pain?

Chest pain...is that what she's here for? We've spent the last hour figuring out her med list. She hasn't been evaluated yet!

In Memorium

I loved him as far as patients go. He was warm, and friendly, and needy. His thick accent always pleasant. Often he spoke in a mix of languages, intertwining one with another. Some I understood...some I didn't. His culture was different from mine. But very respectful. Physicians were held in high esteem.

The diagnosis was horrendous and of course the expected lifespan was short. Often he circled life's drain but usually found away to pull himself back. Long ago he had entered hospice but the truth of the matter was that I never completely accepted it. At least not emotionally.

He had been doing poorly for the last few days. I tried the few tricks that usually worked. Then I got the call this morning that he took his last breath and died..... just like that.

And as per usual I feel a great tinge of sadness and guilt. If I had done something different. Been more aggressive....been less aggressive. Could I have managed things better?

I picked up the phone to call his wife today. She said that she saw him last night. That his stroke induced garbled language cleared for a few minutes and he became very aware. He told her that he was dying and then preceded to give her a series of instructions. Then he said goodbye.

And so he died. And now I sit at my desk and try to discern what I learned from him.....

Maybe as physicians we give ourselves too much credit. That this strange dance of monitoring, measuring, and tweaking is all for naught. That maybe those who are going to live....we help recover faster. And those who are going to die...we help prepare for death.

And sadness, guilt, and blame are all just crutches we use to help maintain the illusion...

that we actually have one iota of control over our lives.

What Color Is Your Parachute?

I remember like it was yesterday. The first week of medical school. The guy with a PhD next to his name handed out a survey. It will take just a few minutes. Twenty or so questions. I attacked the scan tron like a familiar meal at my favorite greasy spoon. A....B.....B....A.

The banality of protocol. Age...race.....years of schooling. And then a simple question:

How comfortable are you with uncertainty?

I scoffed silently as I swayed in my desk. What does uncertainty mean to a medical student? Born into an idea and molded on a concept. Jordan what are you going to be when you grow up...a toddlers eyes hidden under his blankey....a doctor like daddy!

Uncertainty was a joke, wasted on the unsteady. Unschooled in prowess, abandoned by science and logic and abolished by basic college courses like genetics and physiology.

Uncertainty was for the weak! Not for the A++ student that us survivors had become. So we entered medical school and uncertainty was our challenge. Not a question mark but more like a beginning with a tenuous but stringent connection to an end. One just had to search.

And so it became our namesake....our attempt at becoming more...stronger...perfect. Reaching our goal and entering residency we could see the end in sight. The zenith where our efforts are always rewarded, and the sun always shines, and when things do go wrong it is because our attending is not up to snuff.

Until we leave the hubris of training. In the cold , cruel, real world of practice. Where instead of the enemy...uncertainty becomes the awkward bedfellow. Lurking around dark sterile corners, waiting to spring in our most insecure moments.

How comfortable are you with uncertainty?

Ha! How comfortable are you with death...and suffering...and self loathing...and fear?

I guess a helluva lot more then I would have ever expected.

If your not, for god sakes, don't become a doctor!

Attention Nurses-How To Be In The Top 50 Percent

My cell phone rang as I raced down the highway to the hospital.

"Hello Dr. G This is RN from the nursing home.....Mr. S is not looking good"

"What's wrong?"

"Heart rate is 250 and he is unresponsive"

"250? that doesn't sound right....how did you get that number?"

"That's what the pulse ox read!"

"Did you listen to his heart yourself to verify?"

"No"

"OK...whats the blood pressure, respiratory rate?"

"Hold on....let me ask the CNA"

"Never mind....I'm a minute away. check a stat cbc, cmp, get a set of vitals"

I walk in minutes later to find an alert, calm patient. Normal vitals signs and no distress. Apparently he was sleeping and the needle stick from the blood draw woke him up. An interrogation of his pacemaker/defibrillator would later show that he never had an elevated heart rate.

I get these calls all the time. Nurses calling with symptoms and vitals signs that make no sense. Riddled with incomplete information often on patients who they haven't laid eyes on. It drives me crazy.

The good news is that these scenarios do not occur with all nurses. In fact as far as the hospital and nursing homes go....about fifty percent of nurses are excellent. The other fifty percent...not so much.

In reality I don't know the trials and tribulations of being a nurse. It certainly is a complicated and difficult job. I don't want to pretend like I share their experiences. But I have been giving lectures on a weekly basis on nursing care. I believe there are just a few essentials skills that turn a mediocre nurse into a great nurse. Or at least the top fifty percent. Here's what I try to teach in my seminars:

Above all when calling a doctor to discuss a new clinical problem you must ...

Investigate

Please, please, please, please do not call me about a new problem without seeing the patient first. If there is a new rash...go look at it. A warm swollen leg...touch it. Don't take the CNA's word for it. If you call me I am going to ask you a lot of questions. You are going to be my eyes and ears. If you haven't investigated the problem yourself how can you see for me!

Anticipate

S0 the patient has a cough and crackles at the left base. What are the most recent vitals? When was the last chest xray? Is the patient on antibiotics already? Are there any drug allergies. If you call me and want a proper answer to your question come prepared. Have the chart, med list, and most recent labs in front of you. Because I will ask for this information anyway. You might as well have it ready.

Contemplate

Nurses are smart. I repeat most nurses are smart. They bring to the table clinical training, years of experience, common sense, and empathy. When you call me I want your opinion. Does the patient look sick? What do you think is going on?

I can't tell you how many times I have been stumped and turned to the nurse taking care of a patient and asked his/her opinion. Often that opinion helps me generate ideas or answers the question for me. I am secure enough in my abilities to ask for help. This is a team sport.

So that's it. Go from a mediocre nurse to at least the top 50 percent in three simple steps:

Investigate

Anticipate

Contemplate

And I will hold the greatest respect for you.

Migraine

It usually happens after missed sleep. Whether it be the children or a night on call. The first sensation is a an awkward unease. A strange feeling in my eyes.

As my vision skews my mind races to the likely possibility of another headache. I look straight ahead. Lines? Images blur as letters disappear from words. Out of the corner of my right eye... pulsating. Like a disco ball or blinking light whose intensity varies by from second to second. Lightning flashes in and out of my visual field. There is no pain yet. Just the dull, obnoxious feeling...adrift.

By now inevitability. The fear is replaced by resolve. I mentally calculate. How much work is left in the day? How long in the car? I ransack the office for Tylenol. Ibuprofen. If I can I take two of both. As the visual symptoms fade I get ready for the numbing pain.

I used to take triptans but not so much lately. Usually the otc's help enough.

I continue work.....or whatever I am doing. But in slow motion. Like operating underwater...in a fog. As if I had been hit on the head with a baseball bat. The original thud didn't kill me....but a dull, pulsating, heaviness affects my every movement. My every thought.

And I wait helpless. Till the pain goes away. Till the day ends. Till I am lucky enough..... to fall asleep.

They Are All Code Blue Now

"Code Blue ICU....Code Blue ICU"

I was greeted by the PA system as I walked into the hospital this morning. A shiver ran down my spine as I quickened my pace . The days of running to codes are long gone. But since I have a patient In the ICU I was curious and just a little bit worried.

As I walked through the sliding doors I passed the room full of doctors and nurses frantically working. It was not my patient. The ICU doctor stood on the side calmly directing the measured chaos.

And my mind wandered back to my training. As a second year resident I was on call at at VA hospital every fourth night. left alone with a few unseasoned interns and hundreds of ill patients I was the head of the show.

And our patients crashed and burned on a regular basis. One...Two...sometimes four codes in one night. Although it was the beginning of my medical career I was used to it...each of us residents a veteran of hundreds of codes already.

I would stand at the head of the bed. Directing the CPR, medications, Line insertions, and intubations. Some of our patients lived. Some of them died.

We felt like doctors. real doctors. Like the ones on TV....swooping in at the last minute to save the day as family members knelt at our feet in gracious thanks (well not exactly).

But eventually I graduated residency. I became an attending and practiced in the real world...unshielded by academic hierarchy. I was rarely in the hospital when my patients coded. The ICU, nurses, and rapid response teams took over. And the decision process changed.

I still make decisions that alter people's lives. They may not be as dramatic. I no longer pull out the paddles and shock their chest when the monitor starts to buzz. My decisions are much more mundane. To change the medicines. To order the cat scan. To offer hospice.

Much less glamorous. But still fraught with consequences. I may sleep more then I did during residency.

But probably a lot less soundly.

Portraits Of The City 3

The sound was electric. A kind of whirring. The silver faced man with top hat and black jump suit had elbow and knee pads. He moved mechanically in fits and starts. The crowd swayed as the wind blew on a cold fall day. The performer was jacket less. All exposed skin was painted metallic. His face stood still like a mask and betrayed his bodily movements.

Michael Jackson's thriller blared in the background. A meager holiday season, passer buys were more interested in the live entertainment then the big box store that was being ignored in the background.

A small hat sat to the side and a thin man without a coat waited on a bucket turned over. He held the radio close to his body. He watched his counterpart stand on a brick ledge. He kept an eye on the stray quarter or dollar bill that found its way into the meek surroundings of felt and fabric.

A large clerk exploded out of the store. He pushed through the crowd to the front. His arms bare underneath the logoed short sleeve shirt he was no doubt forced to wear. As he emerged the thin man sitting on the bucket jumped up and placed himself between the performer and the clerk.

Even in the cold the clerk had sweat running down his side burns. Heated arguments ensued. The clerk trying to move the crowd away from blocking the store entrance. The performer's keeper fighting for a few inches of turf in this industrialized, consumer jungle.

And the man with the silver face continued to move with mechanical accuracy. The radio drowned out the sounds of the characters arguing. And another Michael Jackson song began to play:

They told him don't you ever come around here

Don't want to see your face, you better disappear

The fire's in their eyes and their words are really clear

So beat it, just beat it

Ah,,,,The Holidays

Something happens the last three months of the year. Every year. It's like clockwork....our lives go haywire. Instead of happiness the holidays bring pain and suffering, malevolence and discontent, and oh ya.....plain old anger. It's a frustrating time to be a physician.

The old people die.

Every year during the holidays. In droves. Inexplicably. Out of nowhere. One or two a week. Sometimes after long periods of suffering. Sometimes, all of the sudden, to every one's surprise. In greater numbers then in all the other months of the year.

The middle aged and chronically ill get depressed.

Highly functioning people become psychotic. As if something threw them over the edge or under the bus. Mental status change is the complaint of the day until it is dethroned by inexplicable pain. All over the body. Immune to the foraging fingers of cat scans and mri's. Resistant to even the most obscure blood tests. Antidepressants are dispensed like life saving oxygen.

The young get mad.

Mad that they feel unease. Mad at our busy schedules. Mad that illness is a resistant and often obnoxious foe that doesn't always bend to the will of the hapless physician. So they yell, and scream, and threaten.....as turkeys bake, carollers sing, and snow carpets the land.

And we....the downtrodden and tired. Beleaguered and feeling abused. Bundle up against the cold ice ridden world. And hunker down.

For whatever comes next.

The Truth Is...I love Internal Medicine

I have spent a lot of time on this blog describing what bothers me about being a primary care practitioner. And while this is all true...I love Internal Medicine.

I love being the first one to evaluate a medical problem.

I love using detective work and Occam's Razor to take a complicated story and develop a unified and cohesive diagnosis and treatment plan.

I love using all my senses to treat medical illness. To listen, to touch, to see...being a good internist takes all of them.

I love forming long standing relationships with my patients. Getting to know their children...and grandchildren...and sometimes great grandchildren.

I love catching a diagnosis that everyone else has missed.

I became an Internist because I felt it was the most rounded, challenging, intellectual prospect in all of medicine. As my role in this medical system becomes denigrated, marginalized, and abandoned...

I wonder If I will love it as much.

Memories of College

It was the beginning of a new school year. I had just gotten out of class on a beautiful fall day. The sun was shining. The warmth bathed my face as Eric and I drifted toward the student union. We strolled through the Diag and stopped briefly to talk to a girl from Spanish class.

We crossed the street and entered a small courtyard. As I turned the corner I recognized a girl's silhouette out of the corner of my visual field. I looked up. She was 20 feet away. Her head lifted and our eyes met. As she smiled I couldn't help but smile back. We both paused as if our eyes were having a silent conversation.

She said. I'm sorry I didn't feel the same way about you....We were the best of friends though...I did love you in my own way!
And I answered. I know. But it wasn't good for me to continue the way we had.
I miss you.
I miss you too!

And then the moment was over. Eric and I entered the union and her image quickly jumped from reality to the recesses of my mind.

We would see each other again from time to time. We even talked once and went for coffee. But it was never the same. The connection was gone.

As the years pass the memories become more distant. And of all the thousands of joys and frustrations of a year of having my soul consumed and stomped on what remains is so little.

Those few seconds.

At the union. When our eyes met and we smiled at each other.

And the pain was gone.

Snapshots From Childhood

We were feuding. As much as I, a 10 year old, and my eight year old neighbor could. The long hot summer days had taken their toll. My mother was busy at work and my dad had passed away. The nanny/housekeeper was tasked with keeping me busy. We strolled out on the front lawn with baseball gloves. I was Ryne Sanberg and Aurelli was Jody Davis (she thought he was so cute!).

Our game was shortly interrupted by Andy (my next door neighbor) and Tim who had just moved down the block. They were both a few years younger then me and had become fast friends. Currently they were united in their attempts to antagonize me.

They sauntered to the other end of Andy's front yard and started to throw a foot ball back and fourth. Aurelli glanced at me with a sense fof foreboding....ignore them...you know they are looking for trouble.

Andy and Tim quickly huddled for a moment and then made their way towards us. Hey...you want to join our football game. I looked up quizzically. My heart and mind paused and then started to wage a silent war. Aurelli shook her head...but it was to late. I put my arms out and Andy tossed me the football. Go long.

Tim ran off towards the other end of the lawn. I took a few steps back and launched the perfect spiral 20 yards down field. Tim put his arms up and the football hit its target square in the chest on the numbers. It bounced off and knocked him over stumbling to the ground.

Tim jumped up and looked at Andy. They both ran towards me. Andy was the first to reach me...Hey what do you think you are doing hitting him in the chest that way? Tim was close behind. Aurelli, who knew better then to leave us alone, stepped forward as Tim lunged toward me. She intercepted him but couldn't stop Andy from joining the fray.

As we rolled around on the ground Andy's father strode out the front door and grabbed his son under the arms and heaved up on his chest. I was free. Then he manhandled Andy and I and beckoned Tim. Come on...were going to your house to discuss this with your father.

My heart sunk and I was overcome with fear. Andy's father was a good man...I knew that. Tim's father was something different. Angry, belligerent, he never had kind words for me.

Moments later we were standing at Tim's house. Andy's Father knocked and a large sweaty man opened the door. He was over 6 feet, obese, his face a ruddy complexion and trickle of sweat omnipresent on his brow as if he had sprung a leak and was continously dripping out the contents of his brain.

He looked down at me and his eyes bulged. Oh no you don't...you're not bringin that kid inside my house...I hate that fuckin kid!

Andy's father took a step back as the door slammed. He was visibly shaken...shocked. He walked Andy and I back to his house and sat us down. Calmly he explained that we needed to stop fighting. That we were neighbors and friends. That life was to short to be angry at eachother. And that Tim's father was wrong and shouldn't have reacted that way.

Andy and I never fought again. In some strange way we felt bonded by such an odd experience. We were kids. It was simple. Tim's father's reaction was enough to make us think that we were to young to understand this adulthood thing. Better to be kids...play football...have fun...let the grown ups figure out the complicated stuff.

But I will never forget the vulgarity. The pure hatrid in those bulging eyes. It's probably been the only time in my life that I have experienced such venom directed solely at me.

Long after the memory of the houses, the faces, or the neighborhood fades away.... the hatred...the hatred is what I will remember.

How To Find a Good PCP?

I was reading a post this morning on Health Beat on CMS's attempts to create a "Physician Compare" website. The idea is that our government will create an easy and accessible site that our patients (ie customers) can go when searching for a physician.

Such information as medical school attended, years of practice, law suite history, and location will be available as well as data representing quality indicators.

I have very mixed feeling about such a site. While on the surface this looks like a good idea....I would challenge my readers to come up with a series of data points that would define what makes a good primary care physician.

Sure...you say...easy. They have to be nice. Communicate well. Have a clean office with good personnel. And oh yah...they have to be good at doing that doctor thing. You know that thing where they diagnose and treat patients correctly. Where they balance the existing medical data, each patients unique situation and needs, and yes even cost effectiveness to come up with a tailored plan.

That so called "doctor thing", which I would argue is the most important quality indicator, is just not so easy to measure. Especially in primary care.

Yes we can tabulate how often Dr. X's perscribes colonoscopies. And how Dr. X's patients Hgb A1c's usually range. We can see how close Dr. X gets to the correct blood pressure goals (even though depending on the data each year these goals are revised!).

But none of that really says a stinkin thing about quality. Sicker, poorer, less educated patients tend to be less compliant. I can offer every patient that walks in my door a colonoscopy but that doesn't mean it will get done.

And then there is the problem of gaming the system. Create quality indicators and physicians will be great at bumping the numbers but what will be ignored at the sake of quality. I know you are having chest pain Mr. Jones...but when was your last colonoscopy? Why is your a1c so high? As seen in England, incentivize physicians to ask certain question and do certain tests. They will be compliant. But it will divert their attention from other important issues.

Lastly, how is the government going to attain such data. Up to this point, medicare is incentivizing physicians to report quality indicators with programs such as PQRI which give bonuses for voluntary reporting. The carrot, however, will become a stick in years to come when physicians will be penalized for not reporting.

So...take beleaguered, unhappy, primary care physicians who are already in shortage and overworked, add more reporting requirements which will take up more of their time and add to their overhead. And see what the future will bring (hint....many less PCPs..which I guess is OK if you don't value their worth!).

The problem is that the number one indicator of physician quality (in my humble opinion) is diagnostic acumen. And that...that my friends is exceedingly hard to measure.

So how do you find a good PCP?

I have no flippin clue!

But if any of you figure it out could you please let me know.....It's hard to find an excellent pediatricians these days!

Are PCP's The New Nurses?

It happened again last week. I received a consult note in the mail. My patient had seen the cardiologist for a follow up on cardiac disease. As I perused the assessment and plan I came across a new entry in the problem list:

1) Dizziness: refer to neurology

As opposed to yelling at the cardiologist and demanding that he refer patients back to me for work up....I called the patients daughter. I explained to her that dizziness can have many causes and only a small percentage of them are neurological. Although, of course, I trust the cardiologist could she have her mother please come see me first before going to yet another doctor.

The mother and daughter dutifully appeared days later. After a few minutes of questioning and a basic physical exam the cause became obvious. She was orthostatic and dizzy upon first rising. Her blood pressure was 90/60. I cut back on her cardiac medicines and followed up by phone two days later. Like magic....her dizziness was gone.

I can't tell you how often this happens. Cardiologists refer my patients to neurologists. Neurologists to orthopaedists. Orthopaedists to ENT. And often if they would just refer back to me I could take care of the problem much quicker (it can take months to get into a specialist) and often with less diagnostic testing.

I am not saying I can handle every issue...but usually I want first crack at it. Because I know the patient, I know the medical history, and I know the meds...I am much less likely to disturb the balance of chronic medical issues when treating somehting new.

But that's the problem with primary care today. We are not seen anymore as the problem solvers. We have lost a great deal of respect from our colleagues and patients.

In some ways I feel we have gone the way of the nurse. Much maligned by both physicians and society, nurses continue to toil behind the scenes with great amounts of knowledge and ability. It's just no one recognizes it.

Some days I am the cardiologists nurse, some days the neurologists, other days the dermatologists.

PCP call the pharmacy and order another months worth of medications
PCP insurance requires a requisition for that test
PCP write out a referral to another specialist because I can't figure this out
PCP the patients dying...go talk to the family about hospice!

Some Thoughts On Hospice

Friday in my office is like happy hour.....for the oldest of the old. They come. 90, 95, 100. Always on Fridays. Some come in wheel chairs. Others walking. Some alone. Others with family. 5,6, 7 sometimes even more in just one short morning. And we talk...about life, about their children, about growing old. I apologize that at that age I really have little to offer. After all... they know more about health then I....they made it to their ninth decade. Some I offer comfort, others medicine, on rare occasion tests. Mostly I just listen.

So it is fair to say that I am used to dealing with geriatric issues. And it is also fair to say that I work closely with hospice and find it one of our best resources in dealing with end of life care.

In reality, my medical training started with hospice. My first clinical experience with real "live" patients was as a hospice volunteer at the beginning of medical school. I started in the inpatient hospice unit. I did everything from laundry, to comforting families, to helping the nurses place dead patients in bags in preparation for transport to the funeral home. Eventually I traveled to patients houses to help with chores and run errands.

Yesterday I signed three death certificates. One died in the hospital of acute illness. Another died in his home with his wife and family present. The last died in an assisted living. They were all hospice patients but each for less then a week.

And I figure these numbers are about accurate. Probably 95 percent of my patients die in hospice. Likely only 10 percent die in the hospital. The other 90 percent die at home or in a nursing home or assisted living. Most of these patients have only been in hospice for a short period of time.

Often when I talk to my hospice colleagues I feel a slight sense of reproach. The conversation ends with a statement to the extent of, "to bad your patient couldn't have enjoyed these services for a longer time period."

I understand these sentiments. I do , in fact, believe that patients with terminal diagnosis live longer with hospice care then traditional management. I do believe the quality of life is better. But the truth is that most of my cases are not so black or white.

Some die of acute illness and the time period from decompensation to death is short...hours to days.

Often my elderly patients and their families are not emotionally ready early in the disease process. It can sometimes take months of conversations to help a family understand that their elderly loved one is slowly fading away from dementia.

Sometimes a patient has chronic illness like COPD or CHF and it is unclear if death is around the corner or a few blocks away. Often I avoid hospice to allow for the agility to move from palliative mode to acute aggressive care without having to explain to a hospice administrator why I want to spend money ordering tests on a patient who they think should have a less aggressive course.

And sometimes I hold off on hospice because the patient is comfortable. The family understands and every ones needs are being met.

I will continue to value hospice services. As time goes on I see the movement flourishing. It is becoming more agile. Moving from palliative to comfort care and back again.

The possibilities are endless.....

We are entereing the golden age of hospice care!

Imprints

I immediately recognized the women as she walked into my examining room. She was petite, pretty, and she couldn't hide the bulging underneath her fall jacket which gave away her late term pregnancy. She was accompanying her boyfriend who apparently had suffered an injury in a mosh pit at a concert a week ago and needed his sutures removed.

"Lisa....Lisa is that you?"
She looked at me with a haze of discomfort and concentration. Her boyfriend (who had been my patient for years) looked on curiously.
"Remember...we used to be friends in High school?"
Actually we had dated for a tumultuous month and then she swiftly broke my heart. That was fifteen years ago. I was an awkward teenager at best...she was my first girlfriend.

Although she assured me that of course she remembered...I could tell by the blank look on her face that neither my name nor my face had brought back much recognition. Amused I chatted comfortably with them as I removed her boyfriend's sutures. Occasionally sprinkling in references to our past and previous friends.

They left as quickly as they came and that would be the last time I would see either of them again. But it wouldn't be the last time I thought about Lisa. Our at least not about her specifically but more about what she represented.

You see...being that I have only dated a few women in my life each of them has left a lasting imprint. For better or worse I remember details....feelings....moments. My dearth of experience serves to magnify the few memories that I have.

On the other hand....for Lisa I was probably one of a number of relationships that neither lasted long nor held extraordinary significance. A normal person may date often before they settle down with that special someone.

And this...this made me think. How often had I made an imprint on others....been part of an important memory..and not even been cognizant of it.

As a physician I am often involved in my patient's lives at critical junctures. How many times have I walked into a room and told a wife that her husband is dying? How many times have I told a suffering patient that there is nothing more we can to do (at least to cure)? How many times have I told a husband/wife/father/child/daughter that their loved one will live?

In my case, I have these conversations so often that they no longer stand out as particularly significant or memorable.

But to my patients....to their families...they may never forget the face and actions of the doctor that day....

the day they were given the news that forever changed their lives.

You Got To Know When to Holdem...Thoughts on Physician Quality

Yesterday my last patient of the day was a young man with a history of multiple surgeries and medical problems. He developed a fever over night to 102 and transient abdominal pain. By the time he saw me his pain was gone but his temperature was still elevated. Knowing this patient as I did, even with the benign exam, I sent him to the ER for a stat cat scan of the abdomen and pelvis and a straight cath (he had urinary retention) for urine. I called the ER Doc to give report before my patient arrived.

From the beginning I was harangued with negative commentary. The Physician shook me down. Why was I sending this patient? The exam was benign why did he need a cat scan. Etc...Etc. By the end of the conversation I simply told the ER Doc...Look, I know this patient..something is wrong. Do the scan!

Two hours later I get a call from the ER. The labs looked OK. He was dehydrated and had a urinary tract infection. His white count wasn't that high. They were going to send him out with antibiotics. So patiently I asked..so what did the scan show?

Of course they hadn't done it. Angrily the ER physician replied, it's going to be negative! Fine we'll do it anyway.

An hour later my cell phone rang. Holy shit....abscess, his temperature is 104. He is going to the operating room now.

And see this is the thing about medicine. Everyone wants to try to measure physician quality using all sorts of strange indicators. Things like blood sugar control, rate of preventative screening exams completed, patient satisfaction. But you see to me...those are all indicators that are highly patient dependent. Either they get them or they don't...often the physician has little to say about it.

In my mind what makes a good physician is a little bit more subtle. In the immortal words of Kenny Rogers:

You got to know when to hold'em, know when to fold'em
Know when to walk away and know when to run!

Snapshots From Childhood-Memories Of My Father

It was too beautiful for words. At least from the perspective of a five year old with greedy eyes and a lustful heart. It was silver, and shiny, and fit perfectly into my little hand.

I watched as my father stood doubtfully at the department store counter. He made a gesture to the attendant and she opened the case and lifted out the object of my adoration. My father took the lighter and held it in his hand. I could see his hand sway gently...getting a feel for the weight of the silver jewel that lay resting quietly in his palm.

He flipped the top of the zippo and it made a wonderful, throaty sound as it opened. Inside a white stranded wick, and a small wheel covering a tiny flint. His thumb fingering the wheel and then giving it a whorl. Sparks flew momentarily and then disappeared.

As my dad looked down at my face he studied my exuberance and then quickly made a decision. He paid the clerk and we exited the store. In the car he opened the lighter. He pulled on the wheel and to my delight he released the inner casing from the shell. He removed the wick, with the caustic smell of lighter fluid emanating from it, and returned the casing. He then handed over the object of my affection.

The lighter was disabled but he left the flint in place. I flicked open the top and fumbled with the wheel. After a few attempts I successfully initiated a spark.

Later that day we drove to summer camp. As I pulled off my seat belt he put his hand out. I fingered the lighter in my pocket and contemplated my next move. I couldn't bare to part with my new found treasure.

He tried one more time...then he warned me. He explained that if he let me keep the zippo I couldn't take it out while at camp. It would surely get taken away. I agreed gratefully and went off to play.

Hours later, my father's warning deeply lost in the recesses of my childhood brain, I pulled out my toy and demonstrated to my friends how to make a spark. Of course I had no idea that the camp counselor was just steps away. She swiftly took the lighter.

I would never see it again.

Years later after my father died I would find a secret stash among his belongings packed in a box.

About a dozen silver zippo lighters...

each beautiful and perfect in its own way....

with flint in place but wick carefully removed

just how he left them.

Why EMR's Are Bad For Helathcare Reform

I was working away in my office yesterday, doing my best to squander our health care dollar, when to my dismay I was hit with a conundrum. The patient in front of me was a young healthy female with right lower quadrant abdominal pain. As I recklessly took a history and examined the patient I formed and incomplete and cost ineffective differential. Her belly was definitely tender. She had a low grade temperature. The list of possibilities danced through my economically unsavy brain. Appendicitis, right sided diverticulitis, kidney stones, gynecologic issues.

Then the answer hit me like a ton of bricks. Gleefully I went to order and expensive cat scan of the abdomen and pelvis. I reached over and picked up the order form and my hand gently moved to the breast pocket of my lab coat. And then it happened...wait for it...wait for it....there was nothing there. I ran, in a quandary, to my desk to find a pen to fill out the form. My desk was picked clean.

And then....then things started to click. My medical assistants and secretaries had been roving the building looking for pens for months now. Slowly but surely they had stripped the doctors office's.

One by one the great pen migration had begun. Months ago. Doctor's in exam rooms and hospitals everywhere had started to feel the pinch. I didn't even flinch the other day when, on my way into the hospital, I was approached by a former friend and colleague. He had a rabid look in his eyes and a uncanny desperation. I quickly brushed him off and assured him that I wasn't hiding any extra pens in my lab coat.

But why...why had the pens in medical facilities become as rare as a primary care doctor who sees his own patients in the hospital?

It was the government. The government had been working for years to curb pharmaceutical influence on our impressionable physician work force and made it illegal for drug companies to use pens as marketing tools. The logic was impenetrable. Ignorant, careless, bonehead physicians were being coaxed to use expensive, harmful pharmaceuticals to the benefit of the industry and the harm of patients everywhere.

The government, however, had no idea how fortuitous this ban could be. Strapped (and cheap) physicians struggling to make ends meet would be very unlikely to replace this free revenue stream by buying more office supplies. As the great pen migration continued physicians would find themselves unable to do the very thing that bureaucrats and reformers have been trying to stop for years. Write new orders!

After all the most expensive technology in medicine is the physicians pen. Now physicians would no longer be able to write for cat scans, mris, and expensive chemotherapy. The health care crises was solved!

And indeed as I struggled to find a writing utensil I did momentarily contemplate skipping the CT Scan and just putting my patient on antibiotics. After all if she actually had appendicitis it would eventually rupture and we would find out soon enough. Right?

But the Obama administration made one fatal error. In its zeal to promote Emr's it forgot that there is one glitch....electronic order entry.

I skipped...nay I ran to the nearest computer. Within minutes I had ordered the cat scan electronically.

Another day...another dollar spent. I guess I could get to like this EMR thing!

Boy....I think I have been reading too much Dr. Rich!

Portraits Of The City (2)

He was fairly odd. Young...in his early twenties. His over sized sweatshirt constrained by a tank top carelessly thrown over. His sweats were just a little too short. Riding up on his legs on each side to reveal black, dry, scaly legs. The colors were unmatching. Gray sweats, a pink sweatshirt, red shirt, no socks, and old beat up white tennis shoes.

His gait was unorthodox. He seem to bounce from step to step. His head bobbing perceptibly up and down and his arms swinging wildly. He shoulders moved side to side with each step.

He had a look of concentration on his face as he entered the playground. It was a rare patch of green amidst the pulsating cityscape. Water tower loomed gently over our heads. The chirping of the birds intermixed with the episodic screeches of a dozen kids. Climbing on jungle gyms, sliding down slides, chasing after each other.

Although the kids barely noticed the new visitor the adults on the playground became rigid. Cautiously they herded their children away towards perceived safety. Cameron and Leila instinctively moved closer as I loitered toward the edge behind the swings.

He walked within ten feet of me and planted himself on the jungle gym. He cast his arms out wildly and began to move in a somewhat familiar manner. He was stretching. Using the wayward structure to twist his body in unorthodox ways. Nothing like the stretching I had done in my workout days.

He continued for a few minutes to carry out a number of bizarre exercises that bore little resemblance to the push ups, sit ups, and dips of my youth. And then he sat for a moment. He looked up towards me with an innocent grin and our eyes met as my head nodded gently.

Then he sprang towards the exit and tottered out. The parents slowly migrated back with their kids in tow. Before long the playground erupted in the joyous rapture of childhood noise.

And I sat as if in a trance. Never quite feeling fear, I was more saddened. He was harmless. Misunderstood. Encumbered by oddity he likely struggled to fit in. So many are born different. Unable to find the human bond with others. Psychologically and physically separated. Like the clothes on his back which failed to match...he failed to blend with society. His pink seemed bizarre when placed next to society's red.

So he ventured out on this beautiful sunny day. Trying to do something adult...like exercise. But he did it is his own way. And he did it in his own place. He had come to the park to be with the children. Not to harm, as some of the parents had thought, but more likely to bond.

After all...in many ways

he probably was one of them.

More On Old Fashioned Internal Medicine-Discussing End Of Life Care

I spend a good deal of time talking and thinking about death. It's unavoidable. Not in a morbid or fearful way....more about how to bring my patients dignity and how to bring their families peace. It's something that I do not particularly enjoy...but I am good at it. I have many patients in their eighth and ninth decades, it comes with the territory.

The other day I was lost in thought as I entered the ICU. It was Saturday morning and the hospital was quiet. I was on my way to meet a patient and her four children to discuss whether to continue aggressive medical treatment or opt for comfort care. As I rounded the corner I ran into a surgeon colleague.

I say colleague loosely because we had only worked together once on a single patient. The last time I had seen him was in that very same ICU. Except at that time we were in a conference room, having an end of life discussion with a large family. Around twenty of us. Husband and children, grandchildren and medical professionals. The ICU attending and nursing staff were there. And of course....the surgeon sat quietly next to me.

I cleared my throat and began my talk. First I summarized to the family and staff the patients medical course...using non medical language. Then I described her current prognosis and the different treatment options including aggressive treatment verse comfort care. Lastly I exhorted the family to picture their loved one a year ago. If she could see what was happening to herself now what would she want us to do for her?

Next the surgeon stood up to talk. Although an accomplished pancreatic surgeon known and respected by many....he was gentle and nonintimadating now. He who so deftly maneuvered scalpel and forceps was just as gifted in oratory. Clearly caring and humble...he described what had and hadn't happened right. He layed out the risks and benefits to the family and gave a pause for them to decide.

After many minutes of discussion the family chose comfort care and hospice was called. The patient expired a few hours later.

The surgeon and I convened shortly after the meeting. He was clearly shaken. His grace and easy communication obviously a crutch to hide his inner turmoil. He confided that he had never lost a patient like this before.

As I stumbled upon him again on this quiet Saturday morning I felt a strong emotional connection. It had been pure chance that we had not worked with each other again. He asked about the patients family and how they were doing.

As I think about this encounter it dawns on me that the surgeon really didn't deal with death much. Not the way I do. He hadn't run multiple family meetings each month. He hadn't watched over the years as patients decline with age and are ravaged by chronic disease. He hadn't formed the intellectual and emotional connections with families that only come after years and the roller coaster ride of health and sickness that each of us eventually endures.

And that's what I think Internal Medicine doctors (as well as family practice, palliative care, etc) do well. Especially those that follow during hospitalization. We deal with death...not in abstract terms but in concrete everyday decision making. We are there to guide families at their time of need. This guidance often comes with an intimate knowledge of the patient and family garnered over many years of contact.

I have great fear that as the migration away from Internal Medicine continues we will lose some of this expertise. And it will be our patients....our patients that will suffer the most.

For Manish

He was my guy. You know...my financial guy. The kind of guy that everybody loves when the market is up. When the market is down....well you know what I'm talking about.

He took me out of pity. The meager sums I saved were nothing near his average client. I was well below his minimum. But we had a common friend. And he liked me....he liked Katie. We were his kind of people. Bargain shoppers. Buy low...sell high. That kind of thing.

Over the years we talked every few months. He would take Katie and I out to dinner before we had kids. Later he would come to the house and entertain Cameron before we could chase our son off to bed and talk financials.

It was a working relationship. But certainly he was the kind of guy I would be friends with anyway. He invited us to his house many times to meet his wife and kids. We always for some reason declined. There was usually something going on. Never enough time.

We eventually learned his story and he ours. About how he met his wife in India. About how he didn't think he would marry and Indian girl. And about his kids and the various activities they were involved in.

It was a relationship. Occasionally it had its turbulence. After all the market was doing horribly. But we still came to him for advice. Sometimes about money. Sometimes about life.

He was kind and considerate. Patient and calm. He always had a smile on his face.

Awhile back he called to tell me he had excepted a job with a new firm. I was proud that instead of expressing dismay or concern about my own financial well being the first thing I said to him was "Congrats...I'm happy for you!" He was surprised. I was the only client who had congratulated him. Later we talked about how we would move our funds over to his new firm. I could care less who he worked for...it was his advice I was interested in.

A week later I called for a brief question about funds transfer. He was in the middle of a meeting but took the time to answer me anyway. Little did I know that those were the last words I would ever speak to him. Thirty minutes later he collapsed in his office. In a few days he was gone. He never woke up.

Katie and I went to his funeral. As I watched his wife and children I flashed back to my own father's death. He died the same way. As I approached the casket I mumbled condolences to his family. And there he was. His face edematous and puffy. Unrecognizable compared to the handsome smiling face imprinted on my memory.

During the ceremony family and friends spoke about his affect on their lives. His clients were especially vocal. A widow talked of how he had promised to take care of her finances after her husband's death. And he had. An older man spoke of how he had traveled with him to India to guide him in search of his parents ancestry and to spread their ashes. He called him his son. There was no blood relation.

Then there was me. The fool that I was...I had thought that this gentle human being was brought into my life to teach me about money. Money! Useless money!

In reality his lessons were much more valuable. Comapssion...Joy...love. All things he gently taught, quietly, in his humble way...by example.

And his distorted face and body lying in the casket. Not a true window into his soul but more an unkind reflection of what I had become.

One last lesson taught by a masterful teacher....

I wonder If I deserve as much.

Internal Medicine-Waiting For Godot?

She was like....Superwoman. A strapping medical visionary probably in her forties. Gray long coat falling below the knees. She strode confidently down the hallway towards the elevator, a father hurrying beside her with his young lanky daughter cradled in his arms. The girl's head nuzzled into her father's shoulder. She was old enough to walk by herself...but clearly she was sick. Unable.

Undoubtedly they were headed from the medical complex to the ER which was a few hundred feet away. As I walked past them towards my own office door one clear thought leaped into mind. Boy....I wish I was a doctor. Then I froze. Wait...I am...I am a doctor. But maybe I no longer feel like that kind of Doctor. You know, the one with a capital D. As in MD. The one who throws caution to the wind and runs out of a full office of patients to escort an ailing person and family member to the ER. The one who rushes out of a crowd to perform CPR on the elderly lady who collapses in the shopping mall.

Unfortunately most of us in Internal Medicine have found our jobs and lives deranged to the extent that we no longer feel the strength and surge of emotion that brought us into the profession in the first place. Most of us have lost our inner Superman. And our patients have grown tired of waiting.

It's been going on for years now. The devaluation of primary care and especially Internal Medicine. It started with the loss of technical abilities. Over the years Internists have given up most of the manual labor. We no longer perform biopsies, place central lines, lumbar punctures, or manage ventilators. We have ceded these skills to specialists.

This loss of technical prowess has had far reaching implications. For one...our patients, as well as our specialist colleagues, no longer see us as doers....they only see us as thinkers.

And this by itself is no big deal. If you need your car fixed you go to a mechanic. And we don't want to be mechanics. So we embrace our new vision as thinkers. We are warm, kind physicians, who a patient can talk to. We use manual dexterity through physical exam and pure wit to solve medical problems.

Except....that over the years physical exam has been undervalued. Medical training has moved to lab and radiology based evaluations. The Internist no longer prides himself on exam skills. Who needs to know the ins and outs of heart murmurs when you are going to order an echo anyway.

So Internal Medicine lost its concentration on manual dexterity...and turned towards mental gymnastics. I am reminded of Rodin's Thinking Man sculpture. We are now the astronomers and philosophers. Physicists and scientists. We can live with that!

Now take the Thinking Man and remove hand from chin and place squarely on mouse. Take other hand from knee and fill with preprinted checklists and practice guidelines. Tell Thinking Man he has 7.5 minutes till his next patient appears and he will have to strike the same pose in the next exam room with a new patient.

What you get is a thoughtless, hurried physician, who feels impotent. He is isolated from his patients emotionally. He is boxed in by a computer that doesn't allow eye contact. He is isolated physically by a loss of manual dexterity and an overwhelmingly belief by both patient and physician that tests are more important than human touch. And lastly he is isolated mentally by rules and regulations, check lists, and inadequate time to fulfill his role as a thinking man.

Our patients are figuring this out. They are leaving our practices and going to minute clinics, specialists, emergency rooms, and alternative medicine practitioners. They are taking on cute names and becoming epatients and creating their own empowerment movement.

They are sick and tired and frustrated by us supposed supermen who are enslaved in straight jackets of cryptonite. They have been here before.

Our patients know what happens when you're waiting for Godot....

You sit around an awful long time....

But ultimately...ultimately..

no one comes!

Portraits of the CIty

Head down.
Feet forward.
Hands Up.
On Michigan Ave.
Where the rich people shop.
Hat in the air.
Catchin quarters.

Head down.
Feet Forward.
Hands Up.
Squattin like a boy.
Curled in a ball
To escape the blows.
Of his father.


Head down.
Feet Forward.
Hands Up.
Watchin shoes.
The more beat up
The more they leave.

Head down.
Feet Forward.
Hands up.
Makin a few bucks.
For the long...cold
winter.

In Memorium-Snap Shots

My son is standing in the Principal's office. Or actually it's not my son...it's me. That's just how I picture myself in my minds eye when I think back to when I was his age. I am struggling with a large winter coat. I lay it on the floor upside down. Thrust my arms into the sleeves and flip it over my head. I pull on my hat. At first covering my eyes and then giggling...push it back upward.

It's the middle of the school day. While I am aware that it is highly unusual for the teacher to have taken me out of class and told me to bring my coat, my young mind has not yet been poisoned by fear of the unexpected.

The Principal's office is drab. Old stained linoleum on the floor and off gray popcorn ceiling. I have a pair of gloves which are tied together by a string and looped through my coat sleeves. I pull them on and hop around the room on one foot making monkey sounds. The secretary raises an eyebrow but remains quiet.

I am expecting my mom to come through the door at any moment but instead her best friend enters briskly. She barely notices me and walks to the secretary's desk. The secretary nods gently in my direction. The friend walks over and grabs my hand....come on honey, we have to go.

I agree willingly but now even in my seven year old brain I know something is wrong.

As we walk out the front door of the school the wind hits my face. It's a cold winter day and I have to concentrate on the steps to avoid slipping on the ice. I stop and look up into my mom's friends face. Where's my mom?

She pauses, takes a deep breath, and then responds coldly...at the hospital. Then a single tear drops down from her eye onto her cheek. Only my adult mind understands the look of pity on her face as she prepares to tell me, a little boy, that my life will never be the same.

Something has happened to your father.

I Wish They Would Just Leave Me Alone

I wish I knew how to express myself. I wish I knew how to put this into words. How the direction of things has just become depressing. How each day makes me wonder how we got to where we are today. And I think back. Back to the beginning.

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.