Are We Witnessing The Death of the Modern-Day Physician?

Pamela Wible recently wrote a provocative article on KevinMD regarding physician suicide. In the seminal piece, she conducts “psychological autopsies” on 3 physicians in training who had taken their lives. She searches for answers and suggests solutions for what has become a problem of epidemic proportions. Whereas her focus on the individual is laudable and instructive, I would like to apply her technique to the profession as a whole. While some physicians are committing suicide or becoming addicted to drugs, others are leaving in less-devastating but still consequential manners: early retirement and nonclinical career paths. To many, it feels like a most-celebrated calling is laboring through its last breaths. I stand here today, scalpel in hand, ready to conduct an autopsy of an honorable profession. Are we witnessing the death of the modern-day physician?

See the rest of my post at The Medical Bag.

Is Less Actually More? Should Your Physician Be A Plumber Or A Violinist?

It seems everywhere you look in health care today, some consultant is telling you that "less" is actually "more".  Less care leads to more quality.  Less expense brings better outcomes.  Nurse practitioners with less training are more cost effective.  Less work hours for residents builds a safer hospital environment.

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.

Is Maintenance Of Certification a Tipping Point? #DisagreeMOC

Physicians are docile.  We are programmed to put the greater good above our own.  We train mercilessly, work tirelessly, and bend faithfully at the alter of those we have vowed to heal.  This is our birthright.  This is the covenant we signed in our own blood when we took our healing oath.  Decry us as they will, no one becomes a physician to make money.  No one devotes decades of education and hardship to take advantage of the system.  There are just too many easier ways to defraud.   Easier ways to earn a buck.

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.

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.

#DisagreeMOC

To Be Noticed Immediately and Judged Subconsciously

I think I will carry two things with me from this experience.

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.

Idolatry

Julie was lost in thought.

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.

A Year Of Concierge Medicine

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.

Attention #HCSM Meeting Planners. Would You Like Me to Speak At Your Event?

The only thing better than blogging is having the chance to tell one's stories in person.  While I have been asked to speak at a number of events over the years, I have developed a new talk that I am especially itching to give to a live audience.  I expect it will have all the emotion and impact of the DotMed 2013 appearance below.



Details
Topic/Running Title: The Medical Narrative, A Tie That Binds Doctors and Patients
Style: TED style, no visuals, no notes
Content: Narrative heavy, didactic light
Running Time: 15-20 minutes

Requirements
Will accept multiple offers, but will give video rights only to one.
Need a few months in advance to arrange my schedule.
Expenses and stipend to be negotiated.

Please respond by email: grumetjordan(at)yahoo.com

I also blog and speak about personal finance.

A Small Island Next to a Hulking Continent; A Parable

There once  was was a kind humble physician who worked for years in an office building across the street from the hospital, toiling day to day to take exceptional care of his patients.  He was open and deliberate, calm and thoughtful.  He himself hired every secretary and medical assistant, every nurse and biller.  His staff formed a protective family who fiercely advocated for both patient and doctor.

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.

Good Luck to the #dotMED14 Crew, @RonanTKavanagh

I don't go to healthcare social media conferences that often.  There are three partial reasons for this.  First, I don't have much time.  Second, I'm usually too cheap to pay for it.  Third, I only tend to go to those meetings that I am asked to speak at.  I'll let you decide which of these three is truly the rate limiting step.

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.

What If Our Healthcare System Made Sense?

The conversation was almost comical, until I thought more deeply about it later.  Apparently I was on "the list".  Insurers make such lists for customers who are  searching for a doctor who accepts their coverage.  Every so often my name comes up on these lists, and I get a smattering of phone calls from perspective patients. Maybe a few times a year.

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?

Coming Up Empty. Does The Government Look Before It Leaps?

A few months ago I assessed a patient with dementia.  I dutifully ordered the appropriate blood testing and MRI.  As I delved further into the history, I was concerned that there may be a component of depression.  Pseudodementia (memory disturbance and dementia like symptoms caused by depression) can often mimic classic Alzheimer’s disease, but resolves with proper treatment.  The best way to differentiate these two syndromes is neuropsychological testing.  I decided to send my patient to a colleague whom I had been working with for years.  He had recently joined a large multi-specialty group owned by the major hospital system in our area.

The patient returned to my office a few weeks later.  Not only did he get the consult, he also was sent directly to the neurologist next door (who worked for the same medical group/hospital), and had all his blood work and MRI repeated.  He was placed on a dementia medication called Aricept.  Now most primary care physicians can manage run of the mill dementia without a neurologist’s input, and many agree with The American Geriatrics Society’s Choosing Wisely campaign that Aricept should be used sparingly.  So it seems my innocent and appropriate neuropsychology consult turned into a very expensive episode fraught with repetitive and unnecessary care. 

What gives?

A recent study in JAMA by James C. Robinson and Kelly Miller examined per patient expenditures for hospital-based practices in comparison to those that are physician owned.  They found that hospital practices were 10.3% more expensive and multi-hospital system owned practices were 19.8% more expensive then private physician practices in the period from 2009-2012.  The goal of the study was to examine the effects of work force consolidation among providers that was occurring at a breakneck pace as a result of Obamacare (for a good discussion of consolidation and Obamacare see Scott Gottlieb's article in Forbes).

Whether intended or not, this is just another example of how governmental policy is both failing to bend the cost curve, and having a neutral if not negative effect on healthcare quality.   In fact Washington has been dead wrong more times than not.  There is no better example than the Medicare demonstration projects.  Lauded as government innovation, these projects were set up to test the most "prescient" beltway policies.  In January 2012 the Congressional Budget Office produced a memo titled: Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment.  They concluded that of the ten projects to date,  the improvements in cost and quality had been negligible.  

More recently there has been a much hype about pay for performance.  Aaron Carroll does a nice run down of how it has failed to show benefits in his New York Times piece.   The promise of electronic medical records and meaningful use was just another disappointment as documented by the RAND Corporation's most recent analysis.  The Bundled Payments For Care Improvement initiative is now well under way and is the next in a long line of "innovations" which is expected to fail.

Looking into the future,  I am strongly in favor of the governments ability to form and test hypotheses.  Demonstration projects can help us predict which policies may actually lead to improved healthcare.  The problem is the government tends to look before it leaps.  Healthcare consolidation,  pay for performance, PQRS, and meaningful use are already prime time even as the studies to prove their effectiveness are coming up empty.

The Not So Humorous Unintended Consequence of Healthcare Reform is Monopoly

Check

The administrator's voice wavered as I picked up the phone.  He was calling about the nursing home patient that I admitted the day before.  While normally forthright, I could feel the discomfort in his tone as he danced around the issue.  The patient's insurer had called.  Apparently they made an "arrangement" with the Mega ACO owned by the latest consolidation of Goliath health systems.  They wanted my patient transferred to another doctor.  Apparently the insurer now required all it's patients to be seen by only medical group physicians.

The administrator was almost whispering now.

The truth is, if it was up to me, I would have you see all our patient's!

The medical group doctor hardly ever rounded.  She was almost never available for urgent calls.  Her patients were transferred out to the hospital at the drop of a hat.  Yet, incredibly, she was managing three quarters of the nursing home population.   But the medical group physician had one advantage that trumped clinical quality or even cost of care.  She was measurable.  Her every move was recorded in an electronic medical system that could be beamed into the greedy hands of administrators, case managers, and insurers at whim.  This data could be analyzed and assessed, and spit back at her with ultimatums and extracted promises.

We sat silently on the phone at a loss for words.  The nursing home could not dare damage the fickle relationship with the ACO.  Otherwise the growing stream of patients coming from the local hospital would diminish.  It had been that way for some time now.  The threat was implicit to the arrangement.  The not so humorous unintended consequence of healthcare reform is monopoly.  And there is a power grab by huge expansive hospital systems for the billions of dollars, I mean patients, ripe for the picking. Physicians and nursing homes, doctors and nurses have all become pawns.  They are fodder for a game playing out around the country.

The administrator was the first to speak.

You know that the ACO will be merging with your other hospital systems soon.

He was right.  It was only a matter of time before they would be kicking me out of the nursing home business and replacing me with some no named company man.  As I began to hang up I sensed a ring of optimism bouncing over the phone line into my unwilling ear.

You might want to join the medical group, we really need you to see more patients here.

I hung up.

Check...mate.

You Are Not Your Data

A few weeks ago, @drmikesevilla (Mike Sevilla) live tweeted a slide from Eric Topol’s (@EricTopol) talk at the American Academy of Physicians' 2014 annual meeting. The slide, a picture of a young man with transparent numbers and data points outlining his face, is silhouetted by words in bold black print: YOU ARE YOUR DATA. This sentiment was a throwback to Dave deBronkart’s (e-Patient Dave’s) 2009 keynote address for the Medicine 2.0 Congress in Toronto titled “Gimme my damn data, because you guys can’t be trusted.”

The idea is that a person’s ability to understand and control their medical records, previous lab results, and even biometric data will lead to more engaged patients and better outcomes. While enticing to blindly follow this logic, there remains a fallacy to such arguments...

Please read the rest of my post at The Medical Bag.

My First Patient Was A Mouse

I didn't think much of it at the time.

Most physicians can trace back and recall their first patient.  For some, it is a clinical encounter the third or fourth year of medical school.  The more creative may point to their cadaver during first year anatomy and nod knowingly.  My first patient was a mouse.   Or shall I say a group of them?

My freshman year of college, I volunteered in the lab of a prominent endocrinologist and studied a new drug to reverse the course of type 1 diabetes.  We monitored genetically bred, non obese, diabetic mice.  Every day we would reach into their cage and grab them as they scurried about.  Then we would rub their bellies inducing urination, swab the urine, and test for glucose. The unlucky creatures with a positive urine test needed to have blood drawn.  The thing about mice is that they don't have obvious vessels like you and I.  In order to get a drop of blood, we had two choices: either cut a portion of the tail or tap the choroidal plexus behind the eye.  The latter approach, while more brutal, was less maiming.

I would take a swab and dip it in ether.  The swab would be applied to the mouses nose inducing anesthesia.  The tough part, while applying pressure to the orbit causing the globe to pop out of the socket, I would slip a pipette behind the eye and turn until blood shot up the tube.  Then, if we were lucky, the mouse would wake up.  If not, we used our fingers to compress the chest performing mouse CPR.  Those mice proven to have diabetes would be randomized to two separate groups.  One would get the experimental injection while the other would get placebo.

I passed many days and weekends alone in the lab.  One sleepy Saturday,  I approached a mouse in preparation for a blood draw.  Mice can be slippery creatures.  The technique most favored was to grab them by the scruff of the neck with the thumb and forefinger, and hold the back tightly with the base of the hand.   So I thrust forward like I had done dozens of times.  I got a good hold, and flipped the mouse around to face me.  But something went terribly wrong.  I must have grabbed too high, or maybe too roughly.  The mouse's body quivered and then shuddered in such and odd and frightening manner.  I reflexively released as the mouse fell to the table.  Dead.  With horror, I realized that I accidentally snapped it's neck.   I will never forget the feeling of life passing so quickly and unexpectedly in my hands.

I occasionally think about this as I watch family members cradle their loved ones in those passing moments before death.  Do they feel the shudder?  Do they experience revulsion or relief?

And I sometimes have fevered dreams about that mouse.  When I toss and turn, unable to sleep because of the crushing pressure of some clinical decision or another.  That poor creature.

That poor creature who succumbed under the weight of my thick, clumsy hands.

Sadness On The Side

The calls came simultaneously.  One from the hospital and the other from a nursing home.  Two deaths separated by fractions of a second.  My heart swelled.  For a moment.  The pile of papers on the desk softly whispered.  My mobile howled jealously vying for my fragile attention.   I could feel the emotion drain as I turned back to the task at hand.  Unexpectedly, my mind wandered back to the wedding in California.

It was a spectacle.  Pre-ceremony hors d'oeuvres with sushi stations and Kabobs.  An open bar long before the utterance of the first I do.  The wedding party bespectacled in gowns and tuxedos danced down the isle as the gala began.  I felt the joy, in every corner of the room, soak the participants in a  humid haze.  It was heavy but far from suffocating.

I held my wife's hand as first the groom and then the bride sauntered down the isle.  The groom paced the full length but then circled back as his bride reached the middle section.  They walked together to meet the Rabbi.  My wife glanced in my direction and saw the tears welling in my eyes.  She looked quizzically before turning back to the ceremony.  I was far from surprised.  

I have been crying a lot lately.  At weddings, during movies, or while watching television  It's something that has grown exponentially over the years.  The barriers of my heart have become weak and the tide crashes into the breakers and spills shockingly on the barren land below.

I have lost control.  And I know exactly why.

It's just that I see so many awful things.  My daily menu consists of death and destruction with a healthy serving of sadness on the side.  I swallow these whole, rarely having the time or energy to chew properly.  Yet all that is pushed down must eventually be digested.  I no longer mourn, for after all these years mourning would have morphed from a hobby to a full time profession.  I neither grit my teeth nor curse a deity that often seems indifferent to the suffering of us poor plodding humans.

Instead I cry.  When it's safe. When the joy becomes overwhelming.

Ordinary People

Cheryl loved to dance.  There wasn't a time in our house when the the kids weren't jumping up and down on the furniture, the radio blasting, and her body swaying in rhythm.  Ironically, we were dancing when it happened.  It was her fortieth birthday.  The kids laughed and clapped as I dipped her dramatically and she sprung back into my arms.  And then she crumpled.  Tony, my youngest, giggled hysterically thinking it was a ruse.  I clutched at her lifeless body, all muscle tone was lost.

It was the emergency room physician who first used the word "stroke".  But what does a plumber know of such things?  In my experience you could always replace the damaged or diseased part.  I clung to this naive worldview as Cheryl was transferred to the ICU.  Tony and Lisa alternated between collaborating and arguing as I held vigil at her bedside.  And we waited.

Everyday the neurosurgeon came in with worse news.  First there was bleeding.  Then an increase in brain pressure.  The nurses whispered about hospice, but no one had the fortitude to talk of such things openly.  I wouldn't have listened anyway.  How does one give up on their lover, partner, friend?  If there is one chance in a million, wouldn't you take it?

The conference room was full of doctors and social workers.  Tony and Lisa stayed outside in the waiting area and played with legos.  The neurosurgeon was severe and agile, a man of action.  He described the procedure to remove part of the skull to relieve the pressure.  The Internist was mousy and meek. He used numbers and percentages.  He assured that it would be OK to do nothing, to let nature takes it's course.  I visualized Cheryl's brain like a drain clogged and stuffed to the point of bursting.  I imagined reaching with my tools and clearing the debris.  I decided to let the neurosurgeon have at it.

The years that followed were difficult.  Cheryl didn't die, but she never recovered either.  And each fork in the road was met with another gut wrenching decision.  Tracheostomy, feeding tube, nursing home.  Her brain severely damaged by swelling and blood, her recovery was tortuous and incomplete.

She did improve.  The tracheostomy tube was removed.  She is able to move her eyes and verbalize some.  The most coherent thing she does is cry.  Everyday, in the nursing home, by herself, she cries.  She is unable to lift her hands to wipe away the tears nor does she have the brain power to negotiate the psychological torture of her daily existence. She just knows that something is wrong.  And it cannot be fixed.

Lisa and Tony are teenagers now.  They try to visit from time to time but they are in the process of building their own lives.  They are stuck in the chasm between childhood and adult.  Their invalid mother is a constant reminder that life can be horrifying.

And I wonder if I made the right decision that day in the conference room.  Maybe we would have been better off if Cheryl died quietly in that ICU.  Maybe she would have suffered less.  But I try not to think about such things too often.

Because Cheryl, Tony, Lisa and I, we're just ordinary people.

We don't always know which way to go.

Parenting And Helplessness

Years later, I now wonder if I overstepped my boundaries.

Nancy was a pleasure to have as a patient.  A physician's assistant in her early twenties, we often chatted amiably during visits.  Our conversations randomly ambled between personal and professional topics.  She recently married and was looking forward to having children.  Her gynecologic history was complicated and after a period of months of unsuccessful attempts to get pregnant, she visited a local infertility specialist.

Although the workup was completely normal, one of her blood tests, while technically in range, was deemed "subpar".  Her obstetrician sent me a letter asking if I would monitor levels and adjust medications.  Appointments were made, labs were drawn, and a few months later a pregnancy test came back positive.

Nancy was overjoyed.  Every so often I would receive a note from her gynecologist documenting her progress.  Ultrasounds were normal.  A litany of screening tests uncovered no abnormalities.  Everything was perfect, or so I thought.

One morning I was surprised to find Nancy sitting in my exam room crestfallen, on the verge of tears.  Her gynecologist was struggling with her levels.  Her previously "subpar" blood test was closer to range, but still had not met the magic number that her infertility specialist had decreed optimal.  With her medical training skills honed from education, Nancy had searched out a bevy of papers suggesting a correlation between low normal values and poor pregnancy outcomes.  Thirty weeks into gestation, She felt like she was in crisis.

While I was unconvinced by the tenuous connection in the literature Nancy produced for me, I couldn't help but feel a lightning bolt rush through my own insides.  How many times had I struggled with these same fears with my own children?  How many times had I painstakingly deliberated over my little ones ad nauseum.  To give vitamins or not?  To treat with antibiotics or wait longer?  Every decision dissected and second guessed.  Each time feeling so sure that my failure to decide correctly would mar my child for a lifetime.

My eyes glistened as I told Nancy that having a child was like ripping your heart out of your chest and then leaving it in the open unprotected by the strong bony architecture of your rib cage.  That to procreate was to feel an uncertain type of helplessness that is unmatched by other realms of human experience.  She will try to control almost every part of her babies existence and fail over and over again.  And yet most likely, despite all her foibles, her child will be more perfect than she ever imagined.

Nancy, I explained, was experiencing the first pangs of parenthood.

We decided on a treatment plan.  We scheduled a follow up visit one week later.  And then she left the office.

I never saw Nancy again.  She cancelled all future appointments

Years later, I wonder how things went.

I often imagine her holding her baby lovingly.

Pressing Questions

Picture your shoulders thrusting forward as you slink into the nursing home or hospital at some ungodly hour in the morning.  Day after day, year after year, your gait adjusts to the facade of the foreboding colossus.  You become boxy, structural.  Familiarity has affected you.

It's not just the hospital, but the patients of course.  Being a physician is just like any other human being, just magnified.   You start with a basic unadorned body of armor.  Certain things penetrate: the first cry of a baby as he leaves the womb.  Others splatter and stain but you don't dare let them in: the swoosh of blood as it spurts out of a ruptured a-v fistula, the screams of fear, and the ever-present sobs of the mourning.  The outsides may become disorderly and unkempt, but the insides remain pristine.  Or so you think.

Patients come and go.  They either die or move away or decide they no longer want to receive care from you.  Hospitals open and close.  You move your office.  There is much transience.  The faces fade and the circumstances become hazy.  But the detritus remains.  You may forget the specifics but your exterior has been marred.  Your armor adorned.

Until the day you realize that you never really had any armor in the first place.  Just porous skin.  Now faded and bruised, you carry these marks with you. That which you relied on for protection has inevitably become a sieve.  Your insides are now also untidy.

And you may find yourself walking through the mall on occasional Saturday mornings with your family. Your children weaving through the isles and ducking under wayward clothes.  Your wife leafing through the discount racks in the corner.  Your phone hangs from your ear as you answer yet another phone call.  You stop mid orders to look at yourself in a full length mirror.  And you wonder if the reflection is really you anymore or some stranger.

The pain only lasts for a moment, and then you turn your attention back to the phone and answer-

whatever pressing question is being posed to you.

For Those Of You Who Worry About Me

Ruth was problematic.  Well into her seventies, her body may have dulled but her tongue was sharper than ever.  And she used it to lash me with complaint after complaint.  If it wasn't her knees, it was her ankles.  If it wasn't her ankles, it was her hips.  I battled the impossible month after month, year after year.  Our interactions left a bitter taste in my mouth.  Nothing makes a physician feel more impotent than the stubborn problems that refuse to bend under our practiced hands.

I am fairly experienced with complex medical issues.  I have never shied away from diagnostic challenges.  But I have to admit that Ruth seemed to push my buttons just so.  I started to dread our visits.  I winced every time her name came up on my schedule.

I am not proud of this.  The covenant between doctor and patient is sacred.   Neither a patient's attitude nor my inability to solve her problems is an adequate excuse for such feelings.  

It all changed instantaneously.  I was walking lazily through the Botanic Gardens with my family one weekend when I spied Ruth a few hundred yards away in the Rose Garden.  She was surrounded by children and grandchildren.  The young ones teased and coaxed as Ruth hopped back and forth with her walker.  Her laughter wafted effortlessly through the air.  She was alive and animated.  Her gait straightened, her limbs moved, and her face was alight with joy.  This was not the same crotchety woman whose visits I had grown to loathe.  I stared awestruck for a few moments before moving on.  

A week later, Ruth hobbled into my office with none of the aforementioned spring in her step.  After making small talk, I mentioned that I had seen her from a distance at the gardens.  I talked of how alive she was amongst her children and grandchildren.  How her laughter caressed each brow, patted each back approvingly.  I saw no evidence of a body crippled by arthritis.

I could see Ruth appraising as I spoke.  She was waiting for me to get to the point.  Eventually I stumbled through my thoughts out loud.  I wondered why I had never seen such joy in the office.  Although I am only familiar with a fraction of my patient's lives, I usually have a distinct feeling for who they are.

As Ruth replied, I could see the the amusement in her countenance at being asked such an absurd question.

Joy?  Meh.  You expect me to be joyful at the doctor's office?  This is where I go to complain about my knees?

Her eyes sparkled and I nodded with a more profound understanding of our relationship.

And so it is with my writing.

The Space Between Sickness And Death

There is much to deplore in our medical system.  Atrocities abound in the dark recesses of hospital wards, the over packed waiting rooms of outpatient offices, and the algorithmic hum of insurance claim denials.  Yet time and again, the most vile of of insults are hurled at one setting in particular.  I'm talking of the place cursed by emergency room physicians when admitting yet another poor soul with a sacral ulcer, a place spoken of by patients and families in the most hushed and fearful of terms.

I am talking of the modern day nursing home.

The allegations of abuse and neglect abound.  The New York Times is littered with stories and editorials claiming inappropriate use of medications.  The view of nursing home owners is a bunch of fat cats, deceiving our elderly and neglecting the flesh in favor of the all important bank account biopsy.  And no doubt, as with any reputation, some of this is true.

Nursing homes endure, however,  because there is no other setting for such patients.  Long after the hospital has discharged and the family has gone home, someone has to take responsibility for our most downtrodden: the poor, the frail, and those maimed by disease.  The extraordinary complexity of the average nursing home patient has leaped forward over the last few decades.  The staff pivot from the average knee replacement rehabilitation to a paraplegic with a stage four pressure ulcer, TPN, and no understanding of the meaning of a polst form or DNR designation.

Our society has chosen to see ultimate darkness in this place it so desperately needs.   Yet, if we are searching for humanity, we must crawl into the places that no light is willing to shine.  We must wade through the morass and stench of human depravity.  Down here in the space between sickness and death you will find us. On our knees.

CNAs, nurses, social workers, administrators, dietitians, therapists, and yes physicians.

Singing, crying, laughing, and comforting.

Perhaps holding your loved one's hand.

Will Healthcare Reform Destroy The ePatient Movement?

The ePatient movement represents everything that is positive in medicine today.  This grass roots force has introduced shared decision making and empowered both physician and patient.  The quality of healthcare dialogue has risen meteorically both in the exam room and out.  Today's healthcare "consumer" is more engaged, more intelligent, and more agile at wending their way through the confusing maze of sickness and health.

It's awfully sad that it has to come to such an abrupt end.

While you may accuse me of hyperbole, there is plenty of reason to believe that the gains made by this important and patient centric revolution will fall victim to the machinations of healthcare reform.  How could legislation made to benefit the populace have such untoward effects?  Its all about intentions.

The architects of the Accountable Care Act and the mountain of legislation that will follow were faced with the difficult task of allocating scarce resources to a growing and unsustainable national debt.  Instead of an open and honest conversation of rationing, the beltway answer was to hire a group of medical ethicists to convince us that population health is more important than the doctor-patient dyad that has been the basis of medical care for centuries.  Thus physicians become the steward of the population, allocating these resources as they see fit to benefit the community.

This version of healthcare is the complete antithesis of the ePatient movement.   Medical decisions are not inclusive, not patient centric, and not up for debate.  This is the ultimate form of paternalism.  The doctor feels that your expensive chemotherapy does not sufficiently benefit society.  There is no discussion.   Such statements would be almost laughable if not for the recent article by Ezekiel Emanuel in The Atlantic.  According to this prominent author and proponent of Obamacare, you (and society) will be better off if nature takes it's course swiftly and promptly if you are over seventy five years old.  And why not?  Zeke tells you it is so.

The ePatient movement extolls taking power away from central authorities (or paternal doctors) and placing it squarely in the hands of the patient.  Ezekiel Emanuel can't divine your values, life goals, or interests.  How can he decide what medical treatments are right for you?

The situation worsens if we consider the new structure of our healthcare system.  President Obama's self stated intention was to collect large groups of doctors into big organizations.  These organizations, he reasoned, would facilitate a team based approach sown together by technology and the abolition of fee for service.  He reasoned that doctors on salary would be much better penny pinchers and stewards of our national piggy bank.

As we have seen across the country, the cataclysmic mergers of hospital systems has created a majority of employed physicians, strapped to computers, and mired in the bog of administrative minutia.  Patients are becoming last in a long line of mistresses.  Physicians answer first to their hospital system, next to their electronic medical record, and then comes the government.  At some point, if your physician has enough time to leave his "team huddle", he may be able to see you a few minutes between most precious key strokes.  You are an afterthought.  There is no empowerment here.

In conclusion, I think the way forward for the ePatient movement is clear.  You have fought like bats out of hell against the paternalistic, backwards ways of the past.  It's time for you to turn your attentions to a more sinister villain.

Your government.

Personal Responsibility And Chaos

She was sick.  Not sick like a high fever, body aches and a runny nose.  Sick like she had spent the last half a decade in nursing homes as most of her internal organs failed.  There was oxygen, and dialysis, and a colostomy.  She propelled herself vigorously through the crowded halls in the custodial wing of the nursing home, her wheel chair a natural extension of her body thoroughly unhampered by bilateral leg amputations.  

She was sick, but she was thriving.  Every hospitalization, every set back, met with a perseverance and a stoicism of body that was nothing less than magical.  The fairy dust unfortunately spread no further than the entrance to her semiprivate room.  The rest of my patients didn't always pull through so well.

So when the biopsy came back cancer, there was little hesitation when she decided on having the surgery.  There were risks, I reminded her.  The chance of sudden death on the operating table was nothing to scoff at.  But I had no reason not to clear her.  The cardiologist agreed.  After much haggling and arranging, a surgery date was set.  A date that fell smack in the middle of my only planned vacation for the whole year.  Seven measly days off.

The surgeon was busy and couldn't rearrange his schedule.  I visited her early morning before leaving town.  She opened her eyes sleepily.  You are going to take care of me in the hospital, right?  She of course new that was impossible, but asked to be certain.  I assured her that the hospitalist group was excellent and would be attentive.

I left town.

Seven days later I returned to find her transferred to a distant hospital.  A few phone calls later my fears were confirmed.  She had a cardiac arrest a day after surgery.  She died.

It is hard to explain to the laymen what personal responsibility means to a physician.  Every death, every poor outcome is studied painstakingly.  A single question pervades this endless search, what could I have done differently?  It's not some sadistic game we play to torture ourselves.  It's more of a ritual.  A safeguard.  The study of medicine is significantly complex, and the foibles of human ability are delicate.  In a world where perfection is unattainable and the stakes are absolute, the only path to sanity is an overwhelming obsession with detail.  We swear to never make the same mistake twice.

For the most part this works.  I never forget to check the EKG of the demented delirious patient in the ER because of the acute myocardial infarction I missed in medical school.

Now, everyone would agree that even doctors have a right to a few days off now and then.  But it's often difficult to turn the demon off.  This obsession with taking responsibility for my patient's well being defies logic.  And I cling to it.  Every day, every moment, with every ounce of strength and might that I can muster.

Because without it, I fear, I will be more likely to become an agent of harm.   And this profession that has flowered in the bosom of my identity, will devolve into complete chaos.

Intimacy

We were intimate.

As intimate as a doctor and patient can become.  He had long outlived his wife and there were no children, no family, just friends.  When he first came to me he was lively and active, but the years took their toll.  Our visits became more regular.  Every six months.  Then every three.

His memory started to slip.  Occasionally he would look at me suspiciously when something went wrong.  His mind no longer able to wrap around the intricacies of medical care, he grasped at what was left.  If he forgot to pick up his prescription from the pharmacy it somehow became my fault for not calling it in.  Like family members do, we had our ups and downs.

But every time I walked into his hospital room after one mishap or another, he always looked relieved  and his lips would curve into a giant grin.  The last such occasion, he had had a stroke.  Although his limbs were working well, the muscles of his throat had been afflicted.  Each time he tried to eat he would choke and sputter.

His stay in the nursing home was disastrous.  His weight plummeted and he lost interest in living. We had long conversations about what could be done.  Although I hated the idea of a feeding tube, this simple surgery would bypass the problem and allow him to live comfortably.  It all made such great sense except that he wanted nothing to do with it.  He was ninety years old and didn't want a tube sticking out of his body.  He was ready.

I consulted hospice and we arranged his discharge.  A week before leaving he presented me with a neatly wrapped box.  I opened it to find his favorite bolo tie.  He wore it often with a short sleeve button down shirt and a cowboy hat.  He wanted me to have it.  I accepted it reluctantly, full of pride and yet mortified at the idea of actually wearing it.

I saw him a few more times in the nursing home before he left.  Each time his disappointment was clear.  He wondered why I wasn't wearing his tie.  And the truth is, I have no rational explanation for my actions.  It clearly would have looked ridiculous on me, but I could have put it on before entering the room and taken it off after leaving.

Decisions don't always make sense.  It's like that when your intimate with people.  You periodically disappoint them.  You can't always explain why.

He returned home, and died a week later.  From time to time I come across his bolo tie when rummaging through my drawers.  When this happens, I feel such longing and also a bit of shame.

Its not that he died, or that my medical care was sub par.  We were both quite comfortable with his decision.  It's the fact that I could have done something so simple, so straightforward, to make him happy.  And inexplicably, I didn't.

I have become fairly comfortable with the premise that occasionally being a human being exposes my shortcomings as a doctor.

It devastates me, however,  that sometimes doctoring reveals my failings as a human being.

Are We Emasculating Our Physicians?

On the face of it, the phone call was relatively innocent.  A family member was confused about the test I scheduled.  Apparently the lab refused to draw the blood.  When I inquired why, I was informed that the patient hadn't been fasting.  I calmly explained to the daughter that fasting was not necessary.  Recent studies had shown little effect on lipid panel results and I was using the glycosylated hemoglobin to asses diabetes.  The daughter, however, said the lab technician was steadfast.  They wouldn't draw the blood unless my order specifically stated: no fasting necessary.  Furthermore, the lab refused to call me directly, I had to hear this all secondhand from the family.

Not a moment later, a fax was returned to my office,  Although I had filled out the durable medical equipment form correctly, medicare wouldn't accept it.  Apparently I had typed instead of hand written the date.

My hospice patient wasn't doing so great either.  Actively dying in the nursing home, I had written a prescription for morphine hours ago.  Unfortunately the pharmacy wouldn't fill my order.  Although I had specified the numeric version of the quantity on the script, I hadn't also spelled it out.  The pharmacist on the phone was less than apologetic.  Government regulation!

There is no question that physicians should not be above the regular pains and hassles of any professional workforce.  I accept that governments regulate industry and sometimes one has to deal with nonsensical rules from time to time.  But the recent systemic demoralization of this highly skilled and trained group of individuals is having untoward effects.

Facing arduous and difficult decisions while being distracted by an ever-growing mound of minutia molded by technocrats and enforced by unskilled labor is nothing less than emasculating.  It is no wonder why the modern day physician is becoming ever more distant and emotionally as well as physically unavailable.

If we truly want to build a high value, high quality version of our healthcare system, we need our physician workforce to feel a strong sense of internal motivation and pride in their work product.

We can't do this if we keep cutting them off at the legs.

All Of These

You want to know what it feels like to be a doctor?

I want to know what it feels like not to be.

There has never been a time that I wasn't a doctor.  There are things that one strives towards and things that reside in ones bosom before the act of becoming has yet occurred.  This has been my birthright.  I could no more have chosen a profession than I could my gender, my parents.

That is not to say that my future was carved in stone.  I suffered as did my brethren through self imposed asceticism, my head buried in text, my eyes watering, my intellect at times crying for mercy.  I did this not out of want or love, but more of unconscious habit.  Buried in the perverse coding of my DNA was a migration pattern, a way forward.

Graduating medical school, finishing residency was less about reaching the tip or peak of the mountain and more growing comfortably into the shoes that I had worn since childhood.  I had matured.

And being a doctor, being a doctor is neither a hobby nor a profession.  It is who I am.  It is complicated.    On occasion filled with terror and regret, fatigue and fear.  Triumphant at times, and downright disappointing others.  Like so much of life, emotions mix and homogenize.  Rough edges become smooth.

A blessing and a curse.

A privilege.

All of these.

The Last Thing On Our Mind

She was having excruciating pain in her pelvic area.  I pulled the sheets down cautiously and noted the bruising encircling the waist and inching towards the thighs.  I finished my exam and retreated to the nursing station of the skilled nursing facility to comb through the chart.  ER records, floor notes, consultations, but no X-ray of the pelvis. There was no mention of pelvic pain.

The emergency room physician had dutifully ordered a cat scan of the head and neck to rule out injury.  The hospitalist had noted a fourteen point review of symptoms.  The social worker had informed the patient that she was admitted as an observation.  He made sure a discharge plan was in place before two midnights which effectively meant that the patient would foot the bill for her whole rehab stay.  Notes upon notes documenting that the patient was not able to return home.  But no mention why.   She couldn't walk.  She couldn't walk because she was having excruciating pelvic pain.

The next day the X-ray confirmed my suspicions.  She had a pelvic fracture.  I called the nurse and ordered an orthopedic consultation.  Although I knew that she would not need surgery, I felt that they should examine her and comment on weight bearing status, etc.

Of course, it was only hours before the director of the nursing home was calling me on my mobile.  No orthopedist in the area could fit the patient it.  Furthermore, the nursing home was doing an investigation and had to prove that the fracture was a result of the fall that brought the patient into the hospital and not an an on site injury.  The wrath of the state weighed heavily on their minds.

So they wanted to transport the patient back to the emergency room.  Document the injury, get an orthopedic consultation, dot the i's and cross the t's.  Don't worry, they will send her right back!  There was no consideration of the cost of such deliberations.  No concern for the discomfort or pain that the patient would have to suffer.

So this is what we have come to in medicine:

Shoddy, rushed hospital care.
Offloading costs from Medicare to the patient.
Bending backwards to meet the requirements of the state.

And the comfort and suffering of the poor patient lying in the bed in front of us,

the absolute last thing on our minds.

The End Of Days

Sometimes my day is like a book.  The first chapter may begin in the darkness of a self imposed corner as a phone call is made.  A voice, full with the thickness of slumber, answers unexpectedly.

I think today is the day.

No matter how many years I have been discussing death I still find myself using poor euphemisms.  The bain of medical school teaching, I often struggle with the directness.  Your mother will die today.  So cold.  So hard to muster the courage and keep one's voice strong and confident.  I used to shy away from such dire predictions.  I no longer do.  Better to tell prematurely than not at all.

I pick up my stethoscope and jacket and move on to the next room, the next hospital, the next home.  And the memory of the fading elderly woman falls into the recesses of my mind.  These days are so full, the plot so complex, that plans are made, thoughts are compartmentalized.  Family called (check), Roxanol and Ativan written for (check), DNR, Do not hospitalize (check).  There is nothing more I can do.

The next stop may be a hospital.  Where a leg is broken, or saliva aspirated, or hearts fail.  The clickety click clack of the computer keyboard is accompanied by the ringing of phones.  Family meetings are carried out in hush tones in corners or conference rooms.  The rise and fall of a chest, a sigh.

I have an octogenarian to visit at home.  He just returned from the hospital after a pneumonia.  He still needed a few more days but was afraid to leave his wife alone.  Her memory is not as good as it used to be.  She had never stayed by herself before.  Fifty years of marriage and she had never slept without him by her side.

Work life quickly intermingles with personal.  I pick up the kids at their grandparents as I absentmindedly squawk into the blue tooth.  Most days there is some activity.  Violin, tennis, or Spanish.  The phone calls pepper my afternoon and evening.  At some point we find time for dinner.  Maybe a short jog with the family or a long walk.  Have you ever seen a jogger talking on his mobile?  That was probably me answering a page.

I might take a quick shower before  bed or watch some TV.   My phone almost always goes off when I am in the shower.  Almost always.

Around ten, I climb the stairs to the bedroom.  After brushing my teeth and hobbling into bed the phone buzzes one last time.  It's the nursing home.  The prophecy from the beginning of my day has come true.  I give my condolences to the daughter and turn off the lights.  I can't sleep.

It's like a book, you see?  There is a beginning.  Then a muddled and twisted middle that almost makes you forget.  But everything comes full circle eventually.  I put my head down and jerkily fade into sleep.

The end of one's day.

The end of one's days.