Monday, December 29, 2014
Never in our entire history have we gotten so much for so little.
A recent article on KevinMD by Arshya Vahabzadeh asks whether shortening medical school is a good idea. A fairly nuanced piece, a balanced viewpoint is given. I was particularly interested in the conversation surrounding time-based verse competency-based assessment. In many ways, I think it is helpful to view the changes overtaking medicine through this lens.
In the old way of thinking, medicine was an art. Like learning to play the violin, mastery was a distant mountain with many peaks and valleys. The climber learned technical skills in the beginning: how to hold the bough, how to read music from the page. These technical skills, however, were the foundation of knowledge, but not mastery unto itself.
Mastery came when technical skills were married with unfathomable degrees of practice, luck, and passion. No one in their right mind would tell the musical genius to put down the violin for fear of over practicing. No one would tell them that less practice is actually more. And so it is with writing, and singing, and even mathematics. Technical abilities can only take one so far down the road. There is something intangible that is only gleaned from exhaustive repetition.
The new view of medicine is that providers are technicians. More like plumbers. Now, I have no problem with plumbers, but once you learn how to change a toilet or unclog a pipe, there are only so many variations. If a plumber can demonstrate their competency in such fields, there is little need to endure more training. Hence the training to be a plumber, to date, has been less arduous than that of your typical doctor.
The educational model for physicians today is becoming more skills based. We now have teams, checklists, and electronic warnings that allow physicians in training to reach competency quickly. They become facile at entering data and awaiting a clinical guideline to pop up on their computer screen. Care plans are less individual and creative, and more standardized.
If this paradigm becomes reality, who really needs a fourth year of medical school? Or possibly a third?
But, I bet the average patient will not be so happy as these changes take hold.
At one's most vulnerable moment expecting a great concerto, a virtuoso, how sad to receive a toilet plunging instead.
Posted by Jordan Grumet at 2:45 PM
Tuesday, December 23, 2014
Accordingly, physicians have been far too accommodating. Rather than rock the boat, we have accepted the spew and encroachment that has come from almost every direction. Lawyers will sue. Politicians will mandate and legislate. Technologists will code and program.
And by and large, we have accepted each bitter pill as it has sucked away the very marrow of enjoyment and professionalism of our field. We have spent our own precious hours learning how to document better, feeding a torte system that shows no signs of being consumed by it's own wanton wastefulness. We have slaved over relentless forms and check marks, each new piece of paper the love child conceived in an orgy of governmental vigor. And we have hunkered down in front of computer systems stoked by nonsensical technology ignoring the very patients they were created to serve.
The result has been a great emigration away from clinical medicine. Early retirement. Suicide. Physicians are fleeing to safer ground. Better to leave, say the humble and meek, then to fight on the bloody battle field. The death of a once revered profession is a fate that is all but sealed. Of course, there is a glut of youths waiting to become medical students. But the medicine they practice will be barren of the art we so often admire today, full of clinical pathways, and largely driven by less trained assistants and secretaries.
The government has mandated it to be so. The lawyers, politicians, and journalists concur. Health care administrators salivate at that juicy stake that has just been stolen off the plate of the so called "providers" and dropped into their lap.
The future had all but been written. The pathway marked and measured. The funeral arrangements made.
Except a tiny overreaching mistake by a greedy group of "once" doctors trying to lap up a small taste of the gravy train. The American Board of Internal Medicine (ABIM) in an effort to boost revenues announced it's new Maintenance of Certification (MOC) requirements. These largely unproven, waste of time and money efforts, did something that all the legislation and finger pointing on capitol hill had largely avoided.
It awoke the heart of the lion in the poor bleating body of the lamb.
Dr. Wes Fisher and a number of his cardiologist associates exploded the internet with opinion pieces and exposes regarding the ABIM, conflicts of interests, and the lack of data supporting such testing. These lone voices have broken the silence of the long barren field of physician advocacy. The visceral response amongst the populace has grown steadily over the last few months.
I believe we have come to a tipping point.
Maintenance of Certification has become the spark that has finally ignited the beleaguered physician. Faced with a nonsensical health care system mired in administrative minutia, we have found a rallying cry that symbolizes all that trampling we have endured over the last few decades. The hope rings out from city to city, that if we can just conquer MOC, than maybe meaningful use will be next. Maybe torte reform is on the horizon. Maybe, just maybe, we can form our own seats at the table instead of be served up for the main course.
We have a number of road blocks standing in our way. Any practicing physician, not being paid by the ABIM, can tell you that MOC is both a waste of time and money. However, it is often a requirement of credentialling at our hospitals. Furthermore, it is only a matter of time before it becomes one of the quality measurements used by the government to determine payment. These facts must be uncoupled in order to move forward.
I think we must speak clearly with a united voice.
The ABIM board of trustees should be fired, all conflicts of interest must be disclosed.
The MOC should be abolished or radically changed.
The AMA and the ACP should pressure the ABIM for these changes or we should withhold our membership fees.
Will this be the death knell of our proud profession or the shock that brings us back to life? Only time will tell.
I disagree with the MOC.
Posted by Jordan Grumet at 1:40 PM
Monday, December 22, 2014
My body dropped. Almost instantaneously. One minute I was jogging next to my wife, the next my mouth and nose were hitting the pavement. I must have slipped, my foot must have caught. There was no time to anticipate the pain, not even a millisecond to reach out my arms to cushion the blow. Moments later, I felt the sting upon my upper lip and the taste of blood. I rolled back and forth on the ground trying to shake off the searing heat arising from my face.
My wife dropped to the ground to comfort me. Pedestrians stopped inquisitively and pulled out their mobile phones ready to call an ambulance. I stood up shakily and composed myself enough to ward off the attention. And we hobbled home, my wife and I. The blustery wind permeating my light jacket and sending a chill through my aching bones.
At home, I surveyed the damage as my children peered around the bathroom door cautiously. My front tooth was chipped. My face was bruised, and the skin beneath my nostril was irritated and angry. Looking in the mirror, it appeared as if my nose was bleeding, although when I wiped the area there was scant debris on the tissues. My hands were swollen and sore.
My Friday dinner plans were ruined. We ordered a pizza, sat on the couch, and watched a movie. I gingerly maneuvered the crust around my mouth avoiding the front teeth that were tender and numb. I fell asleep immediately, and woke up early next morning ready to go to work.
Almost every part of my body ached. My swollen hands screamed as I turned on the sink faucet. My chest collapsed as I picked up my work bag. And my lips were still puffy and bruised with the ever present appearance of nasal bleeding.
I hobbled into the car and sped towards the hospital. Every left turn required a twisting of the wrist that sent lightning up my arm. As I pulled into a parking spot at the medical center, a spasm of fear over took me. Once glance in the mirror confirmed my worst fears.
I looked funny. All day long I would have to explain what was going on with my face. All day I would see the inquisitive looks before the words formed on people's mouths. I was abnormal. I was a monster.
Forty eight hours later, my tooth has been fixed and the bruising has abated. I still have pain when I complete almost any movement, but it's getting better.
But for a moment, I was the outcast. Distorted and bruised, I had a small taste of what it feels like to be disfigured. To be noticed immediately and judged subconsciously.
And to be in pain. Not the minor aches that we all feel from time to time. True pain. The kind that makes you aware of every movement. Every step.
In a matter of days, I'll be completely back to normal.
Many of my patients, however, continue to struggle with maladies that are far less kind.
Posted by Jordan Grumet at 6:32 PM
Thursday, December 18, 2014
Her right pointer finger slowly traced the edges of the metallic trinket. It was tucked far enough into her pant pocket that only the longest digit could reach. Back and forth, her hand moved caressingly, pausing from time to time to inspect any irregularity, any imperfection. In such a manner Julie built a mental image of the old forgotten piece of jewelry. Her hands visually occupied a space that her eyes had long abandoned.
There was not much to the frigid, sterile room A few rickety chairs. A worn carpet. Some posters placed haphazardly on the wall. The smell of bleach wafted through the waiting room and mixed with the alcohol emanating from where the IV had been placed in her forearm. Julie had grown used to the metallic explosion of iodine assaulting her palate shortly after the injection. There were all sorts of explanations. It reminded her of fear.
She drank it in. Every few months. Much like her mother had. Cat scans and blood tests, radiation and chemotherapy. At least there was action. Waiting is what slowly killed her mother. Desperate moments lost in rooms such as these. Waiting to be poisoned. Waiting to be irradiated. Waiting to be informed and then consoled. If one could string all those moments together side by side, surely there would have been enough time for one last trip to Mexico, or maybe Vegas.
Julie's mother allowed the life to spill out of her in such a pathetic, untidy manner. She grasped the tarnished cross in her hands. She never bothered to remove the chain, although it was seldom worn around her neck. She would clutch openly at the pendant while she waited, until she was called back to the office. Then she would slip the cross back into her pocket, and hurry after the nurse who most likely had already disappeared behind the cantankerous doorway.
No matter how hard Julie tried, she couldn't stem the flood of memories that threatened to drown.
The night her mother died, her father fastened the necklace on the lifeless chest, haughtily displaying all the agony and fear. He said it looked nice.
After everyone left, Julie leapt to her feet and snatched the horrid idol from where it lay. The flimsy chain snapped and disappeared into the murky abyss of the casket.
It was the last time that Julie would ever touch her mother,
or see the hapless chain again.
Posted by Jordan Grumet at 12:10 PM
Wednesday, December 17, 2014
A year ago, I embarked on a voyage at the leading edge of modern-day health care. I abandoned my traditional office-based practice of 2000 patients for a much smaller membership (concierge) model. My reasons were varied. They mostly focused on the dwindling time and concentration afforded by so-called “advances” in medicine, such as electronic medical records and the ever-increasing deluge of paperwork that plagues today’s physician. As I begin year 2, I would like to share a few things I have learned...
Please read the rest of my post at The Medical Bag.
Please read the rest of my post at The Medical Bag.
Posted by Jordan Grumet at 12:38 PM
Tuesday, December 9, 2014
And he prospered. For a time.
The winds of change were slowly gaining force in his small town. His beloved hospital joined a larger medical Goliath. His fellow practitioners abandoned their private practices, and eventually became employed by one medical group or another. Office overhead was on the rise. Each year he looked carefully at the cost of medical insurance for his loyal employees. Each year he wondered how long he would be able to afford such steep increases.
He valued the control of owning his own business, but most of all, he wanted to expend as much energy as possible in the care of his patients. So when an administrator from the hospital came knocking at his door, he couldn't help but listen carefully. These were difficult times for the lone physician. Would he not be better under the protective shell being offered?
He felt unbearably isolated in his current situation. He was a small island next to a hulking continent. His practice was in good financial shape for the moment, but how long would that last? He better be proactive and join the medical group before the offer was rescinded.
He was assured that all parties would work together to provide the best clinical care possible for his patients.
He felt great relief when the medical group's office manager arrived. He literally handed over the reins of every administrative task that was drawing him away from the examining room. The clouds parted, the air cleared, and free to concentrate on that which made his heart sing, this humble physician prospered once again. For a time.
The medical group embraced a new practice called open access. All walk in appointments were accepted regardless of severity. Physicians were asked to work more nights and weekends. When he argued with his office manager about such changes he received a response that was hard to argue with.
He was assured that all parties would work together to provide the best clinical care possible for his patients.
In order to do so, the doors must be open to the customer when they have a perceived need, regardless of how minor. Besides, medicine is also a business, how could they attract more patients if they were not providing the same services as the competitor down the road? Furthermore, since medical group primary care doctors were no longer seeing patients in the hospital (now using hospitalists), he would have plenty of time to meet the unmet needs of his clientele.
Although he missed taking care of his patients in the hospital, and he bristled at the nontraditional hours, he once again adapted to his new situation. And he prospered once again, for a time.
The medical group was exited about the new meaningful use regulations put forth by the government, and quickly partnered with a company that provided electronic medical records. Instead of dutifully working in his office one morning, he sat in front of a classroom full of grumbling doctors being instructed on the newest medical record technology.
This humble physician, however, was a terribly slow typist. He found fiddling with his fingers difficult when he was trying to concentrate deeply on his patient's complaints. He lamented that his hands were awkwardly occupied when he wanted to reach out for the shoulder of a sobbing husband or wife, child or parent.
He was assured by his office manager that all parties would work together to provide the best clinical care possible for his patients.
Electronic medical records when used meaningfully, as defined by the government, would maximize clinical integration and lead to leaps forward in collecting and utilizing big data. He was also reminded that his clinical productivity was flagging, and that the bonuses and eventual penalties of not complying could bankrupt his practice. Although he found it ironic that all of the sudden it had become "his" practice, he put his head down and tried to confront all the changes he faced in the office. Except, he did not prosper.
Confused by the electronic medical record, unaware of what had taken place with his patients when they were in the hospital, and crazed with the checking of boxes, it was a short time before the quality of his clinical care began to falter. Months later he received his first summons.
The torte system was arduous. Hours of preparation and deposition took their toll. All the virtues highlighted by the practice manager became vices in the judiciary system. He was chastised for his consuming medical record, and second guessed for not visiting his patient in the hospital.
He faced the onslaught alone. There was no medical group representative on the stand with him. There was no reassuring voice at night when he climbed into bed with a head full of doubt and eyes that would remain open thirsting for sleep.
His office manager was unapologetic when confronted with accusations of leaving him out to dry. It was not the administrative staff that was responsible for such things.
He was assured that the medical practice is a business and could only survive as long as it made money. It was his job to provide the best clinical care possible for his patients. Not theirs.
He was then fired.
His low productivity could no longer support the hefty administrative burdens needed to run the medical practice. Perhaps they would hire a nurse practitioner.
Posted by Jordan Grumet at 12:54 PM
Thursday, December 4, 2014
The DotMed 2013 conference, however, was an exception. I was asked ( I also begged/pleaded/cajoled some people-you know who you are) to come to Dublin and speak on the topic of narrative medicine and social media.
The trip was magical. Dublin was everything I could have hoped for: friendly, gregarious, cold. The hosts and speaking venue were impeccable. We met for dinner before and after the event. There were bars, and food, and alcohol (gasp!), and banjos.
But really, it was two aspects of the trip that really make me jealous on the eve of DotMed 2014 which I will not be attending. One is that I got to give the talk of my dreams. A narrative that I had been building over years of blogging and decades of life lived. A presentation that was, for me, pure joy. There is nothing better than getting up in front of a group of people and talking fluently about something you are truly passionate about. I live for these moments. Every blog post I write is a mini sermon. A talk I'm itching to stand up and give.
The other, of course, is the utterly cool people I got to meet and spend time with. The creators, speakers, and attendees were a group that I truly admire. Their words, ideas, and laughter will stick to my bones long after I have sloughed off the minutia of what had been said.
A year later, I am still in awe of all of you that I spent such precious short time with.
It's like it was just yesterday.
Good luck to the #dotMED14 crew. Enjoy.
Posted by Jordan Grumet at 4:54 PM
Monday, December 1, 2014
This particular call came around three thirty in the afternoon. My personal assistant had already signed over the phone to me, so my office number came right to the mobile. I answered quickly expecting one of the nursing homes. The voice on the other end was hesitant. He was looking for Dr. Grumet's office, but quickly realized he had the doctor himself on the phone. This felt odd for a guy switching physicians because the next appointment at his current practice was two weeks away. But his toe was hurting something fierce and he was desperate.
So he searched his insurance web site for a list of available providers. He quickly crossed off any physician that belonged to his current practice or the hospital based medical group because he knew from experience that those doctors rarely had openings. They almost never returned phone calls. Although I do not accept his insurance, I somehow had landed upon the sacred list he was scrawling through anxiously.
He told me that I was the tenth phone call he made. He came up empty with the first nine doctors. Many claimed that they were closed to his insurance because they were too busy to take on new patients. One was retiring in a few months. Another was leaving medicine to work for a pharmaceutical company. A third was transitioning into a hospitalist position.
I regrettably informed him that I would be happy to bill his insurance but also charged a yearly fee for non covered services. He paused for a moment. I could feel the wheels spinning in is head. He hated to pay extra, but was dumbfounded to find that he was actually talking to the doctor himself without jumping over any roadblocks or scaling any walls. His foot ached. And I knew that it would probably take little mental effort to assess and treat his problem. Whether stress fracture or gout, infection or inflammation, I felt certain that I could help.
We talked a little longer. Not about his medical problem in detail but more what was happening to our healthcare system. It was a pleasant unhurried conversation. He eventually decided that he would try his luck with the rest of the names listed in front of him He thanked me profusely for my time and hung up with a sigh of resignation.
I hope he found the care he needed. I doubt I will ever hear from him again. These types of calls rarely end in the signing up of a new patient.
I wonder if he marveled, for just a moment, about how easy it could be.
What if you could talk to your physician whenever you needed to?
What if Doctors and Patients had time to form strong mutually respectful bonds?
What if our healthcare system made sense?
Posted by Jordan Grumet at 4:01 PM