Friday, May 30, 2014

Be Not Brave (My Advice For New Residents On July 1)

Be not brave,

For bravery is the crutch of the buffoon, a poor substitute for knowledge and skill.  Experience is a tireless teacher, and practice is the master's apprentice.  Mastery precludes audacity.

Fear and pain will neither be your foe nor enemy, they will be a constant companion.  Much like a shadow, they may progress or recede.  But they will never disappear.  The walls you so expertly build will only create new reflective surfaces, they will obliterate nothing.

Intention is always the first principle.  You will help many but harm a significant few.  Intention is the common  thread.  It is that which separates you from the knave.  When intention is compromised, skill and knowledge have no backstop.

You will never be a carpenter.  Your walls will be porous.  They will not protect you.  Good and mal humors will still exchange,  Just slower.  More painfully.

In the road to becoming, there will be many moments of compromise.  Compromise is a well whose origins run deep.  Be weary of those who proffer money and prestige.  Administrators, politicians, and technologists will all sleep comfortably with your decisions.

You, however, may not.

Saturday, May 24, 2014

We Will Always Have This (My Response to @vkhosla)

As I have said before, when done correctly,  doctoring is an act of love.

It is founded on the most basic of human interactions, intimacy.  Patients open their doors and closets revealing a treasure trove of brutal humanity.  Physicians dedicate themselves to healing, to upholding a sacred covenant born of tears and blood.  It is a partnership, a carefully rehearsed choreography.

The dance is ancient.  To speak and be heard.  To be studied,  To have one's shoulder caressed gently, one's joints manipulated,  and the pitter patter of one's heart auscultated.  This is the birthright of all humans.

Bearing witness to grief.  The well intentioned touch of the hand.  These are things humans do for each other.  These are things that will never be replaced by technology.  Revealing my deepest fears to a computer will not make me whole.  It will not reach over, put it's arms around my shoulders, and tell me that everything will be OK.  And even if it could, I wouldn't believe it.

People like Vinod Khosla forget this when they talk of the future of medicine and technology.  Those who spend so much time opining on medical care, although never having delivered any personally, don't understand how intimacy and healing intertwine.

I could not give up eighty percent of what I do with patients, and than expect that intimacy to be there for that other twenty percent.  Familiarity and trust grow from the mundane.  I could not expand my panel to thousands, and have enough time or emotional energy to build such intricate relationships with each one.

Technology can log millions of data points and whiz through thousands of algorithms in a blink.  But it can't look you in the eye and get you to reveal your secrets, your inner most fears, or your thoughtless details. It can't press your hand in urgency.

As flawed as we flesh and blood doctors are at diagnosis and prognosis, we will always have this.

We will always have this.

Saturday, May 17, 2014

Why Physicians Are So Pissed Off

The process of becoming an excellent physician is one of mastery.  The passion of the child is replaced by the studiousness of the teenager, and the bottomless energy of the young adult.  The leap from decision to clinician takes decades.  Forged in the steel of experience, trampled by pain and tortuous repetition, ability accrues.

The apprentice guards his knowledge closely.  He bows to the alter of the sacred skill that he will do anything to attain.  There is nothing above becoming.  The mountain has many peaks and valleys.  One never quite reaches the summit. There are only gradations of closer.

The height of all these struggles is the clinical visit.  When done correctly, the conductor brings order, coaxing each nuance forward at the appropriate time and pushing back.  Pushing back.

Mastery of this process, this clinical encounter, means everything.  The pride and joy of a lifetime of work is condensed into a moment.  This is where knowledge meets art, passion becomes healing.  The only thing more sacred than the skill of the trade itself is the motivation that brought each craftsman to this place.  The hope to help our fellow human beings is what coats the bottom of the well.

But mastery has it's limits.  The conductor becomes less effective if asked to also manage the lighting.  Nuance is lost if water balloons are hurled on stage during the most dramatic moments of performance.  And so it has become with physicians.  The dictates of electronic medical records, meaningful use,  and preauthorization are destroying the carefully crafted skill of diagnosis and management.  The drivel of healthcare reform has become the fodder of the clinical visit.

Physicians arms have been tied behind their backs.  Now we are being blamed that no one is guiding the ship.  You can't demand that doctors improve healthcare quality and cost, yet handicap our most basic unit of skill, our mastery.  You can't complain that we are doing a poor job, yet pull our laser like focus away from the patient and point it towards a computer.  You can't have your cake, and eat it too.

We complain about salary because it is obvious.  In the face of greater regulatory demands, increasing overhead, and more intense scrutiny, physician salary has been flat when adjusted for inflation.  For must of us though, money is not the issue.  It's more about value.

The demonization of a once proud profession will not solve our problems.

It will, however, alienate us from those we are supposed to be serving.

Saturday, May 10, 2014

Can I Get An Amen

It's time for the American physician to stand up.

We will no longer bend to the tyranny of bureaucracy, the venom of litigation, or the naivete of legislation.  For we have spent many a night sweating on the phone as our dear administrators slept comfortably in their beds stuffed with hundred dollar bills.  Our experience standing in the line of fire dwarfs that of any attorney questioned by his client's peers.  And we have tended to more constituents personally than any verbose and hyperbolic politician.

Yet the doom and gloom of our current healthcare system is being flung belligerently at our feet.  The American physician is beaten, battered, and toiling in a cocoon of self hatred.  Caught in a tangled web that binds, our detractors count on our sacred healing oath to imprison us in a system that becomes more constrictive by the day.  We are too proud to stand down.  We are too dedicated to our patients to bow as the chains are pulled tighter.

We have been judged by the outlying ice that melts at our extremes, and denied the strength of our inner core.  We are solid.  We are dependable.

You will legislate, you will regulate, you will under compensate.  And we will nod our heads willingly.

But when you attack our pride, our character, you cross the line.

We have spent every waking moment since childhood planning for this.  We have studied more hours than most can conceive, We have worked while others rested and than worked some more.

We have been placed in the most difficult of situations.  We have had to question God regularly.  We question ourselves.

We stand tall and proud as American Physicians.

We will not let you cast us as villains.

Saturday, May 3, 2014

A Jordan Grumet Blog Delivered In Person

If you have 20 minutes and want to know what it is like to experience one of my blog posts in person, check out my comments from DotMed2013.

Friday, May 2, 2014

Why I Don't Agree With @aaronecarroll

I have often spoken of the doctor-patient relationship as a covenant. Our patients bear their bodies and souls in exchange for a thoughtful, engaged, respectful partner in navigating health and disease. This dyad, this trusted space, allows for the breaking of cultural norms and full disclosure.  Proper healing is an agreement, it is a relationship.

Although often not spoken of, any successful flourishing healthcare system also requires another sort of covenant; one between provider and society.  Let me explain.

Being a physician has changed me. For someone who naively went into this profession hoping to help people, the reality is much more nuanced and difficult.  I make decisions hourly, daily, that have a profound affects on people's lives.  As a mentor once told me, each successful physician has a graveyard full of patients with their name on it.  While I am not that cynical, I have no doubt that even with the best of knowledge and skill (and following medical guidelines and standards to the fullest), people have died by my hand.  I am not proud of this.  The thought keeps me up at night and wakes me early in the morning.  It literally turns my insides.

I have to live with this.  Day in and day out, my decisions, treatments, or lack thereof may have immediate and devastating consequences.  There is no other profession with such a dire moment to moment routine.  Policeman and fireman spend just brief seconds of their career making such split second decisions.  Judges, lawyers, politicians, even air traffic controllers rarely deal with these imminent vagaries.

This stress, this fear, breaks us.  It can turn the unlucky into a cold shell of a person, a far cry from who they used to be.  Those who are introspective enough to recognize PTSD can, with the right struggle and support,  learn to once again become effective, emotional human beings.

Being a physician takes it's toll.  Not just on our psyches, but on our relationships, on our children.   In many specialties the ring of the phone is incessant.  Government regulations have become so strict that every time a patient scratches themselves, a physician gets a phone call. Birthdays, anniversaries, vacations, and graduations have all been interrupted.  And what is one to say to the poor patient or family. Sorry I couldn't answer the phone to help your poor dying husband, I was at a birthday party?

The hours are difficult.  The work is arduous.  And many more battles are lost than won.

But there is a silver lining, a saving grace.  Along with the above outlined struggles comes something, that for many of us, makes it worthwhile.  Many of us will gladly exchange the heartache and pain for what we believed was our due when we went into medical school.


We expected that society at large would understand the sacrifice of being a physician.  The hours, the culpability, the stress.  That instead of pointing a finger at us, blaming us for the financial downfall of our system, or beckoning us to defend ourselves in court, a hand of solidarity would be extended much as we try to do for our patients.


The idea was that a physician would be provided for commensurate with the amount of hours and difficulty of the work.  This work, a calling, should garner enough income to keep the lights and heat on.


When governmental regulation and intrusion becomes primary, we have lost our way as a society.  Physicians derive meaning from taking care of patients, trying to heal, and comforting.  The flurry of paperwork, meaningful use drivel, and insurance hurdles leave no time for the best part of our job.

This is the covenant I speak of between physician and society.  Physicians will do arguably one of the most difficult jobs in the world in exchange for respect, reasonable compensation, and the freedom to use their skill in meaningful ways.

@aaronecarroll believes that some physicians are crying wolf.

I believe the medicare data dump, meaningful use, and the SGR mess are signs that the covenant has been broken.  Maybe physicians are not dropping medicare yet, but they are retiring early.  They are choosing specialties outside of primary care.  They are emotionally divesting from their lives work and leaving the patient confused and unsupported.

They are turning their pagers and mobile phones off when they leave the clinic, and letting someone else handle the mess.