Does Your PCP Feel Like A Doctor Anymore?

We both agreed that it was unfortunate.

I sat on Paul's living room couch with a computer perched on my lap as he recounted the events of the last few weeks.  His business flight was interrupted by severe spasms of cough and high fever.  He called me upon landing, and based on my advice, went to a local urgent care center.  After waiting for a few minutes, he was seen by a friendly and competent physician who diagnosed him with pneumonia.  Antibiotics were started, and he was given the name of a local physician to follow up with in a few days.

Paul was never the type to rest.  He took the antibiotics, and plowed through his business meetings as if he was completely healthy.  Luckily, the fever abated, and his cough resolved.  By the time he appeared in the physician's office, he felt much better.

The doctor was kind enough.  He peered down at Paul through a conservative pair of spectacles balanced precariously on the tip of his nose.  Although he appeared in his late fifties or sixties, he could type on the computer as agilely as his younger counterparts.  After listening to the chest and finishing his electronic note, he declared Paul cured, and got up to leave the exam room.

Paul stammered and sputtered for a moment, caught off guard by the briskness of the doctor's exit, and asked for advice about his colitis which the antibiotics had exacerbated.  The physician turned his head, and glared at his patient as the rest of his body was already leaving the exam room door.

You might want to consult a doctor about that!

Paul searched around the room thinking he was on a candid camera show.  But he found no cameras, no laughing audience, or genial host.

As he recalled the visit, sitting comfortably in his own home, he figured this was the doctors way of letting him know the conversation was over.

I agreed, but couldn't help but wonder if this physician felt like so many primary care doctors around the country.  He was overwhelmed by electronic medical records, rushed by a a waiting room full of grumpy patients, and reduced to a box checker, list follower, and specialist referrer.  He didn't have time to deal with the really complex problems anymore.

In fact, he no longer even felt like a doctor.

Certainly not the kind he had been trained to be.

Good News

Janice had come to terms with her disease.  The swelling in her legs and the shortness of breath were overwhelming.  Her gasping for air with almost every movement made the sedentary life her only option.  Her family members had long since moved away or died. 

She was alone.

The current bout of heart failure had been severe enough to land her in the hospital again.  The paramedics shook their heads in disgust as they hauled her out of her cluttered, cockroach-infested apartment.  The ride to the emergency room was her first trip outside of the confines of her four small walls since the last hospitalization.

Janice wasn’t depressed; she was just tired.  Her heart could no longer support the mass of edematous flesh that hung wantonly from her body. The cardiologist confirmed what she had long expected.  The damage to the cardiac muscle was too great.  The floppy organ was pumping at less than 10% the normal strength.  The blood confirmed another heart attack.

It was with grave faces that the team of doctors gathered to give Janice her options.  Her prognosis was poor.  She would likely die in weeks, maybe months.  They waited solemnly for what they expected would be a melancholy reaction. 

But they were wrong.

Read the rest of this post at The Medical Bag.

Words

It's metoprolol.

m-e-t-o-p-r-o-l-o-l

The nurse on the other end of the phone sighs as she tolerates my tirade regarding pronunciation.  They all know that I am particular about such things.  For metoprolol is neither metoclopramide or metalazone, and the difference could be life altering.

I live in a world of words.  Trained in a language created to parse pertinent details.  Dysarthria or dysphagia?  Paroxysmal nocturnal dyspnea, dyspnea on exertion, or orthopnea?

Each variant a spectrum of flavor.  A morsel chewed, swallowed, and digested into its basic parts to be rattled off in staccato sentences between physicians.  A meaning conveyed to bring like minds to similar conclusions.   A common language among colleagues to convey a story, to solve a mystery, to make a plan of attack.

And my patients words carry similar weight.  The accent on a particular syllable drawing significance unconsciously to a hidden meaning.  An atypical descriptor pushing the diagnostic engine toward a nefarious path.  The absence of content, words carelessly unspoken.

My patient's future becomes precariously perched on such ambiguities.  My ability to interpret separates durable medical care from chaos.

So you will have to excuse me if I occasionally get caught on words.  If I become stuck on pronunciation or am a stickler about meaning.  

I gently correct the cardiologist as we pass in the hall.

It's Rothberg not Rothschild.  R-o-t-h-b-e-r-g.   

And she died two nights ago. 

Google Hangout Interview with John Bennett

John Bennett and I discussed my book this evening on a google hangout.

Legacy, Some Thoughts On The Death Of Jonathan Crombie

My wife loves Anne of Green Gables.  And every so often she scours Netflix or Amazon Prime looking for the movie to play for the kids.  She is almost always unsuccessful.  Last night, however, she was able to find a version on you tube (with Spanish subtitles none the less).  She popped a bowl of popcorn, and we all settled down to watch this ageless classic.

We were engrossed.  How could you not fall instantly in love with "Anne spelled with an E".  Her hyperbolic and histrionic nature all the more endearing as the plot grows.  Of course, you can't help but like Gilbert also.  At first painted as a bully in his opening scene with Anne, it becomes clear that his jeering words are a school yard ruse to hide his growing affections.

It was around the half way mark that I sadly saw the breaking news on Facebook, Jonathan Crombie (the actor who plays Gilbert) died of a brain hemorrhage.

All the sudden, for me, the story took on greater significance.  Unlike his family and friends, I will never know what kind of man Jonathan Crombie truly was.  Yet his art, his acting, will leave an indelible mark on those of us who grew up with this timeless story.

Of course, it all makes me contemplate legacy.  My father, who died from the same malady at a similar age, left behind a wife and three young boys.  There are also countless patients, physicians, and students who remember his influence thirty five years later.

We all hope that the best parts of ourselves live on long after we have passed.

Legacy is an especially prickly issue for those of us who yearn to create.  The builders, actors, artists, poets, and writers.  For most of us, the act of creation is a lonely and solitary process.  The birth of our "art" is often a complicated and painful labor of love.  We continue day after day, year after year, not for glory or recognition, but because we have to.

That which we produce, the performance we act or the words we write, are the distilled parts of ourselves that we leave for the world.  Long after we are gone and our families have mourned, maybe there will be a little something left.

A word, a phrase, a small bit of wisdom that will find the wayward stranger and bring knowledge, understanding,

or a comforting salve for unhealed wounds.

Fixing The Primary Care Crisis by @Drschimpff

The American health care system is in crisis.  Year after year we see prices rise and quality of care spiral downword.  The more money we throw at the problem, the worse things get.  A bevy of politicians, health care consultants, journalists, and even doctors scurry relentlessly for a solution to to this colossal mess.  But, until now, none of them have understood enough to distill the disparate facts into a coherent plan of action.

That all changes with the publication of Dr. Stephen Schimpff's treatise:

Fixing the Primary Care Crisis: Reclaiming the Patient-Doctor Relationship and Returning Healthcare Decisions to You and Your Doctor.  

And I'll take this moment to lob my one and only criticism at the book.  Dr. Schimpff cogently argues that primary care is the linchpin of high-quality, low-cost care.  Thus, in reality, I believe that the title is more aptly "Fixing the Healthcare Crisis".  Anyway....

Never have I read such a concise and soup-to-nuts explanation of what has gone so awry in our current system.  Our lopsided PCP to specialist ratio, coupled with increasing overhead, and poor reimbursements has turned our doctors into referral machines.  The primary care physicians, forced to see in excess of 20 patients a day by an insurance system that under values cognitive medicine, have chosen the path of lease resistance: referrals, diagnostic exams, and procedures.  It's not that they don't want to give stellar care, it's just impossible.

Good, high quality medicine, requires time.  A luxury that is no longer afforded to those MDs who want to keep their doors open and also collect a paycheck.

The solution is less patients, better reimbursement.  Dr Schimpff outlines several ways to achieve this goal including direct practice models, concierge, insurance incentives, and employer based wellness programs.  He tackles current trends including ACO's, Patient Centered Medical Homes, and retail pharmacy clinics.

But most importantly, he defines a path forward to correct our mangled version of healthcare.

It all starts with our primary care physicians.  Give them less patients and more time to think.

I highly suggest you get the longer, more articulate version of these sentiments and buy Dr. Schimpff's book!

Expiration Date

Everything eventually expires.

I looked down at the bottle of natural spring water in astonishment.  It had an expiration date.  Scanning the empty hospital cafeteria on an early Sunday morning, I wondered what on earth about spring water could go bad?  It had no living parts,  Nothing that serves as nourishment for wayward bacteria or fungus.  The container was sealed.  Pristine.

I figured it was another fiscal hoax, perpetrated on unsuspecting consumers.  You better drink that water fast or you'll have to throw it away and buy a brand new bottle.  I could hear the ka-ching of the cash register as some billionaire somewhere just increased his fortune by a dollar and a quarter.

It was a short two flights of stairs up to the ICU.  Enough for me to contemplate how we so readily believe the little date imprinted on so many of our products.  We throw away perfectly good food.  We dispense of old medications.  There are other things that outlive their usefulness: cleaning products, beauty supplies.

We accept, that for most possessions, there is a natural beginning and end.  Sure we may take that old clunker to the mechanic over and over again.  But eventually it ends up in the junkyard just like every other automobile.  There is only so much that can be fixed.

People, on the other hand, are not allowed such luxury.  We replace the warn out parts when we are able.  We prop up ill and disfigured joints with canes and walkers.  We extirpate nasty cancers and use pills to counter misanthropic metabolisms.

Unlike water, however, we are very alive.

We are faulty.

And no matter how much we refuse to believe,

our time on this earth is finite.

My Review of Becoming Nursey by Kati Kleber (@NurseEyeRoll)

I could never be a nurse.  It's just too hard.  Not only do they have to physically take care of patients (and their body fluids and waste products) but emotionally support said patients, their families, their doctors, and supervise an army of certified nursing aids.  Did I mention that they also must diagnose, manage, and  monitor disease in real time?

It was under these auspices that I came across Becoming Nursey by Katie Kleber while I was working to promote my own book.  I checked her out on twitter (@NurseEyeRoll) and was intrigued enough to jump on Amazon and buy the book.  I was very glad I did.

This is a must read for new nursing graduates, students, and anyone who dreams of entering this sacred profession.  The practical information contained in this book is priceless.  Everything from surviving nursing school, to passing board exams, to organizing your time as a floor nurse is covered.  The text is a clear, organized, and easy to follow set of instructions for tackling day to day challenges.  How I wish I had this type of manual for medical school and residency!

What I think is almost more valuable, however, to not only nurses but also doctors and the community as a whole, is the emotional candor of the book.  Often humorous, sometimes heart-breaking, Kati paints in broad brush strokes the humanity of the profession in general.

We laugh at the descriptions of the physical pitfalls when she describes tackling the not so delicate parts of her job, and we cry when she tells of the emotional hazards we all face while caring for our fellow human beings.

Buy it.

It's a great read!