Swindled

You've been swindled.  At least that's the conclusion I've come to.  It wasn't the hucksters or the snake oil salesman.  It wasn't big business, big medicine, or some greedy hospital administrator.  It was most likely pharma with a large dose of helping from your doctor.  Plain and simple.

I've learned quite a bit being a hospice medical director.  Covering dozens of new admissions a week has given me much insight into doctor prescribing habits.  Often it is my job to decide with meds are necessary and covered by hospice, which are necessary but not covered by hospice, and which are useless.

Do you have any idea how many useless and often harmful meds our patients are on? I'm not just talking about end of life, but healthy patients to.

Can we talk multivitamins?  Almost every patient I encounter is prescribed a multivitamin.  Healthy, unhealthy, living, dying.  When your in the grasps of stage five thousand and one lung cancer and your brain is riddled with mets, you have no business being on a multi.  It's not going to help you.  It's not going to provide that last bit of energy to overcome the calamitous collapse that is approaching rapidly.  In fact, there is plenty of data to suggest multivitamins are harmful if not neutral at best.  Even in healthy people.

How about Vitamin D?  I swear to g-d, every patient I encounter is on some sort of D supplement.  Never mind that the vast majority of medical evidence implies that supplementation is unhelpful in most disease processes.  Yes, there is osteoporosis, but otherwise, it is a non starter.

Aricept in patients who don't walk, don't talk, and barely interact with the world around them?  Again, started often because there is no other treatment, profound dementia patients are submitted to a host of side effects including diarrhea and syncope without the faintest glimpse of medical benefit.

Vitamin C, Vitamin E, Calcium?

How about statins in patients without a history of coronary disease with end stage-opathies  and malignant cancers.  Do we really think we are going to cut down on cardiac events in the fleeting few months that these patients have to live?  Is there any data to support this?  You better believe that these patients get myalgia and other side effects.

Antibiotics for foul smelling urine, screening urine cultures without symptoms, or agitation in an already agitated patient.  It seems that treating non-utis has become the national past time of our healthcare system.

I could go on and on.  Don't even get me started on antibacterials for non bacterial infections.

The point is, we are not being careful with our prescribing habits.  We are not taking into consideration the wealth of evidence and data regarding some of these treatments.

And we are not being good advocates.

We are not shielding our patients from harm.

 

If you want to hear more stories about medicine and personal finance, check out The Earn & Invest Podcast.

And We Must Breathe

Ask any parent.  Having children is a supreme act of faith.  This revelation does not come easy to one who is particularly uncomfortable kneeling at unfamiliar alters.  It hurts my knees.  Yet there is no more durable truism.

It starts with birth.  The awareness of our own unique helplessness is overwhelming.  We are a slave to our children's genetics, environment, and wholly uncontrollable luck.  We skitter to command a million details to defray the constant anxiety of that which can't be governed.  We worry, lose sleep, and panic till the day we feebly shrug our shoulders and accept.  Then we defer to faith.  Because faith is air, and we must breathe.

As my daughter has grown, that faith has transferred from the intangible nebulous, to the burgeoning humanoid sprouting at my feet.  A far more comfortable leap, a sense of control sets in.  As parents, we can lead by example, teach, shape, and mold.  Destiny has temporarily released her grasp.  My daughter can learn not to climb on the hot stove, to look both ways before crossing, to stop, drop, and roll.

So you would think it is the consequential stuff that I struggle with, but often the ephemera nips just as gratingly at my heels.

A few weeks ago, my daughter informed us that she wanted to perform in the annual school talent show.  Each year, we battle to convince her to play the violin, something she actually holds a sprinkling of talent for.  Sometimes we win, others we lose.

This year she decided that she would perform a solo dance routine, and no matter how much I tried, she could not be dissuaded. My anxiety rose as I pondered our weekend dance performances in the family room.  Rhythm, it turns out, may not be at the top of my daughter's otherwise many talents.

Much discussion was had, videos were You Tubed, lists were made.  And two days before the performance, it was clear that her best option was to free style the whole routine.  My heart raced as I pondered her up on that stage in front of hundreds of people, awkward, and embarrassed.  This has been a hard year for her at school, and the last thing I wanted was for it to end in shame.

My daughter, however, was implacable.  She repeated over and over again:

I got this!

The day of the event, she pushed us out of the way and applied her own makeup.  I marveled at the mix of eye liner and lipstick (something we otherwise would never let our daughter wear).  She looked fierce.

When she took the stage at the tail end of the show after fifty other acts, I stood nervously with camera in hand.  She awaited patiently through three attempts to queue her music correctly.  I could no longer control the fluttering in my chest.

I keenly felt at that moment something, in retrospect, I have always known.  

That I will follow this girl with all my heart down whichever path she leads.  And I will have faith even though the journey will often be awkward and painful and sometimes...

Sometimes joyful and wondrous.

Changing Lanes

I drive a fast car.  Which if you know me, is quite uncharacteristic.  I would say that it is one the few possessions that generally doesn't reflect upon who I am.  How I chose this car, the make, and model, are a long story not to be discussed here.  But let's just say that it has quite a kick.

These thoughts jostled through my mind this morning as I pulled into the hospital parking lot.   A recent momentous decision, I surrendered my privileges at this hospital and started using the hospitalists.  It had all become too hard.  The inane compliance issues with the new EMR.  The ER attendings admitting my patients without calling me.  The slew of protocols, documents, and attestations at this institution recently became particularly onerous. The administration was pushing out the primary physicians with the indignation of a million not so subtle pinpricks.

I was making a courtesy visit.  I had asked the Emergency Room physician to have the hospitalist call me the night before.  I knew this patient exceedingly well over the years, and had a good impression of what had happened.  I was unable to relay this information, however, because I never got a phone call.

I didn't agree with the diagnosis or treatment plan.  The admitting hospitalist was no longer available and the nursing staff had no idea who to call.  I carefully documented my knowledge of the patients past medical history, exam, and my thoughts in a progress note.  I also left my mobile number and begged the rounding physician to call me.  I am not hopeful.  Eventually, after much searching and paging, I will likely reach the physician by the end of the day.  Que sera, sera.

This hospital is in the midst of a major rebuild, and part of the process is a new entrance to the expressway adjacent to the parking lot.  The beauty of this new pathway is that following a few careening turns, the entrance ramp is a straight shot for a few hundred feet.

This morning, I came to a full stop after those turns, and waited for the cars on the expressway to pass at 60 mph.  I put all four windows down.  Then I put the pedal to the metal.

10, 30, 50, 70mph,  I sped past all the cars ahead of me.  The wind blowing into the car and smacking me in the face.  Power, speed, freedom, joy!

Eventually I merged left and began the process of applying the brakes.  I was coming up quickly on a series of cars driving at more conventional speeds.

The fun is over.  It couldn't last forever.

It seems it's no longer our patients that we answer to.

Because I've been told, in no uncertain terms, it's time to stop bucking the system.

And get back into my appointed lane.

Letting Go

You can let go now!

As Hannah's granddaughter clutched at her skeletal fingers, the blanket fell to the side revealing the faded serial numbers on her forearm.  The family gathered, yet again, to say goodbye.  This time her acrid breath had lost humidity, her respirations dry and raspy, the extremities mottled with a bluish tinge.

Death had visited the neighborhood before.  Lounged in the parlor.  Nibbled on crackers and tea.  But letting go was not so easy. Sure the signs were there.  There were the bouts of unconsciousness lasting days.  The hours of irregular breathing with long gaps.  The clutching of chest and recitation of prayer.  All followed by merciless, unrelenting recovery.

Hannah wanted to die.  At least that is what she told the doctors.  She sang it in her sleep and whispered to the hallucinations that pranced on her pillow.  She refused medications.  She spurned nourishment.  She pulled at the tube thoughtlessly plunged into her abdomen a few hospitalizations prior.  She hissed at the Rabbi as he entered her room.

Why won't you take me?

They said she was a survivor.  A code they used in order to avoid talking about dark things. Guilty things.  She was forever marked by the fact that she didn't succumb.  She didn't die.  She was scarred somewhere deeper, more profound, than the ugly thing on her forearm.  She was marred by persistence.

Most of her family died decades ago during the war.  A whole lineage erased. And yet she persisted.  Her colon removed, her brain stroked, her heart fibrosed.  And yet she persisted.  The years passed, friends and lovers gone, a child or two perished.  And yet she persisted.

Persistence had entwined her DNA, calcified her bones, and cascaded past blood cells forever traveling in circles.

Her body was failing, but her spirit couldn't let go.

No matter how much she begged and pleaded.

It didn't know how.


Five Moments, now available on Amazon.


Also available, I Am Your Doctor: and This is My Humble Opinion.

If  you want to hear more stories about medicine and personal finance, check out the Earn & Invest Podcast. 

Drip Drip

Get out.


It was not so much the words as the overall tone of the interaction.  The doctor-patient relationship had been generally affable.  There was the usual exchange of pleasantries over the years.  Questions about family, children and grandchildren.  It was a good relationship.  Until Harvey got sick, that is.


Originally there was weight loss and fatigue.  The initial physical exam and slew of testing showed nothing but a frail, cachectic, middle aged man.  A few cat scans later and he was in the oncologist's office discussing chemotherapy.  A regimen was decided on, and therapy began the next day. 


Therapy was hard.  Nausea. Retching.  More weight loss.  Far from feeling better or cured, Harvey could feel the clothes slipping from his emaciated body.  It was as if life itself was drip dripping away as the chemo bulldozed into his broken veins.  And this pissed Harvey off. 


He lashed his family.  He cursed his friends. He spun into a whirlwind of the most resistant depression. A depression, his therapist would later tell me, whose only salve was anger.  While the anger allowed him to carry on, often he left those around him scorched.


His doctors were no exception.  We often spent half of each visit withstanding abuse before getting down to the business of the appointment.  He blamed us for the cancer.  He blamed us for the lousy response.  He blamed us for the side effects of his abysmal treatment.


So when I walked into the hospital room to tell him the scans showed his latest chemotherapy had failed to stem the red tide of death, I have to admit that I had already somewhat detached.  How could I not?  Although he was fairly lathered by the results, it was the mentioning of hospice that finally led to my expulsion.  His wife ran after me with tears in her eyes.  I'm quite certain that she paid dearly for her kind act of decorum.


Harvey died shortly thereafter.


I am prone to remember the pleasantries Harvey and I enjoyed before his health deteriorated.  I am neither disturbed nor saddened by the anger.  I cannot even say that I would not have been the same way if I  had been lying in his hospital bed.


What surprises me, in retrospect, is how little he affected me.  How his anger didn't penetrate the hardened shell. 


Over my career I have been yelled at, cursed, blamed, hugged, and even loved by my patients.


And like the poor life force oozing out of Harvey's beleaguered body, it drip drips down my back.


 And into a forgotten puddle on the ground.


My new book:  Five Moments, now available on Amazon. 

If you want to hear more stories about medicine and personal finance, check out The Earn & Invest Podcast,

  

Five Moments Book Excerpt

“Dad . . . you can let go now.”

Thomas heard his daughter’s voice from a distance. It awakened him from his reverie. He relived those five moments of life and took their lessons seriously.

Rejoice in the ordinary as if you were a child seeing everything for the first time.

Unconditional love can lift you up. 


Forgive yourself over and over again. 


No matter how much we deny it, we are who we are.

Some of the most difficult battles are those in which we choose not to fight.

Thomas opened his eyes and smiled. He looked at the faces of his family before him. After all these years he finally got it. He understood the meaning of existence that eluded him till now.

Eternity . . . Immortality . . .

His family was now joined by numerous others. Thomas’s friends and colleagues, his patients and students, even the man he once gave a five-dollar bill to on the street. They were all there. He gave a part of himself to each of these people. And each of them had given a part of themselves to others. There were thousands, if not millions, of people in the room with Thomas.

His life had meaning. Like a rock falling into a pond, his goodness made a small splash with the people around him. But the waves from the rock rippled throughout the pond. Thomas would live forever. Parts of him were dispersed into the world. And those parts would live and thrive. Thomas’s body was dying but his soul was strong. He felt oneness with his fellow man.

For a moment Thomas thought if he just had enough strength he could share this beauty with his family. But then he realized this was not the sort of thing someone could teach. Each person had to experience it himself.

Isabella’s word’s came back to him as he drifted off.He remembered sitting on the kitchen floor with his daughter and granddaughter the day she almost choked to death.

“See, Dad? It wasn’t all in vain.”

Thomas experienced one last thing before he died.A cool sensation started at the back of his head and washed over his cheeks, shoulders, body, and into his toes. With pure joy, he recognized this as the first sensation he felt upon exiting the birth canal.

Beginning and End. Birth and Death. They were all intermingled in this beautiful dance called Life.

Thomas’s heart stopped.

Taken from Five Moments, now available on Amazon.

When A Loved One Dies

At first you'll query reality.  You will hear your own words, but they will be foreign; apart from you.  The ground will still reassuringly push back against your toes when you walk out the room, but you will wonder if they are your feet-your ground.  Like in a movie, you will negotiate the world convincingly.  Yet, you are an actor playing a part.  A role.  It is not the real you.  

Be assured that this will pass.  Life has changed incomprehensibly in a fraction of a moment.  It will take a few more moments for your psyche to advance accordingly.  This is not disconnection.  This is not denial.  It's shock.

Grief will not be far behind.  Overwhelming, discoloring, disjointed grief.  Some will try to ignore it.  Others will wallow.  How you manage this grief says more about who you are and less about the gravity of the loss.  There is no correct way to map this journey.  We each travel this road separately.  

My gentle advice to you dear traveler, is remember that separate does not mean alone.  Others will not feel what you are feeling, but that does not prohibit sharing parts of your journey.  The most arduous, at least.  Surround yourself with people and things.  Even if they have lost your interest.  Even if they have lost meaning.

Interest and meaning return.  The sun rises and falls.  You will not break.

By far, the greatest danger lies ahead.  In the days and weeks and years.  You may be plagued by a demon so fastidious it will devour your hours, conscious and otherwise.  It will haunt long nights and merciless days.  It will cause the ground to shake relentlessly under your feet, knocking you off balance.

I'm talking of guilt.

You will feel guilty for not spending enough time, or spending too much.  For not calling the nurse right away,  or calling too quickly.  For pushing the morphine that last time, or withholding it.  Even the quiet and peaceful deaths end here.  It is loves last grappling with earth-shattering loss. We are not programmed to let go of that which we cannot control.

And we can't control death.  So we feel guilt.

This guilt will plague you.  It will turn grieving from a process to a permanent state.

Don't let it.  Your loved one died because it was time.  Nothing you did would have changed that.

Forgive yourself.

Let this forgiveness be one last act to honor the dying.  


If you like this post, please order my new book of short fiction, Five Moments.

If you want to hear more stories about medicine and personal finance, check out The Earn & Invest Podcast.

Five Moments Now Available

If Thomas were to write his own eulogy, these surely wouldn’t be the five moments that he picked.  In fact, it’s safe to say that these were memories tucked away in his subconscious.  Yet as he lay on his bed anticipating death, he relived these precious minutes as if they just happened...

And so begins my new book of short fiction, Five Moments. 

This collection of short stories approaches the foibles of the human condition, often as seen through a physicians view point.  Crafted over years, each draws from my experiences as a caregiver, a parent, and human being.  

During the marketing of my last book, I Am Your Doctor And This Is My Humble Opinion, I found that above all the interviews, reviews, and assorted media-It was you, the reader, who carried the greatest impact.   

So if you like what you read here week to week, please...

Buy the book!
Share on Facebook!
Tweet on twitter!
Rate on Amazon!
Post to Linkedin!

You are the most effective marketing force.  Your help is much appreciated.  

Five Moments can be purchased here.
I Am Your Doctor And This Is My humble Opinion here.  

Neither Was Mine

There are parts of medicine that are horrendous.  Moments too painful to recount.  Events that will break even the most innocent participants.

And then there is unspeakable magic.

I live for the days when a patient comes to the office with a particularly vexing set of symptoms.  Specialist after specialist bows their head in disagreement.  Laboratory values whisper falsehoods  with jeering tongues.  Symptoms are transient, physical exam signs inconsistent, and in the midst of head scratching an answer mysteriously appears.  Maybe a common presentation of a rare disease.  Or a rare presentation of a common disease.

Explaining with words so fast that sentences jumble.  Ideas merge.  The patient shakes their head enthusiastically less because of deep understanding, and more because they know that my excitement means that finally the answer will unfold like a blossoming flower selflessly bearing its pollen.  I will eventually slow down enough to present a cogent explanation.  And things will get better.

It lifts me up when a patient sits down beside me after yet another round of chemo.  When, at the end of the day, I have a sparing moment to settle in for intense conversation.   I bite my tongue, become quiet, and listen.  I hear of hopes and dreams.  I hear of pain and suffering, joy and fear. We talk like doctor and patient.  Like friends.  Family members.

We get past the intangibles of life and death, and move on to the more palpable like dignity.  Upon finishing, we leave the room in strength.  We leave the room with resolve.  We leave the room with tears in our eyes.  All of us.

And I love when an unwitting pattern is recalled from the deepest depths of memory.  The clock is ticking.  Heart beats rise and fall rapidly.  Knowledge accrued from past struggles presents itself at the most opportune time, and a life is saved.

On the triumphant drive home from the hospital, with the radio blaring, I remember the patient whose back such life saving knowledge was attained.

And I rejoice that all their suffering was not in vain, and neither was mine.

A Difficult Patient

I have come to believe that humility is an essential component of wisdom.  Never have I found this more true than in the practice of medicine.  In fact, for almost every atrocious professional error in judgment I have made, I can pinpoint the exact moment where I stopped being humble.

Yet time and time again, humility quickly disappears when dealing with the difficult patient.  In fact the label, difficult, assumes the problem lies within the patient and not the technique being utilized by the care provider. Already blame is turned outward and personal responsibility abandoned.

A few years ago, when I was in a group practice, one of the senior partners had a particularly needy patient that somehow showed up on all our schedules from time to time.  Her aged joints carried her into the exam room to their own particular hobbled rhythm.  She paused before each sentence, her voice barely above a whisper.

Her litany of issues was long and nonsensical.  And this was always the precise moment when humility left the room.  We all became convinced that her complaints were largely psychosomatic.  And we were right.  It still amazes me at how cavalier I can be when I think a solution is either simple or non physiologic.

It was only after several visits that the need for a thorough exam became apparent.  I tapped my feet and waited outside the door for what seemed like an eternity as she undressed and climbed into the unflattering gown.  My stethoscope stumbled over the heart as if its mighty muscle had not thumped hundreds of thousands of beats.  Auscultated the lungs absentmindedly untouched by the unmeasurable volumes that glanced the porous surface.

My hands fumbled over the fibrosed joints that absorbed the shock of a child's prance, a young athlete's stride, and an ancient shuffle.

My conceit, however, unshakable as it was, was shattered by the faded serial number tattooed on her forearm.

And my humility, once again, was restored to a respectable level.

  

No Longer There

The phone is ringing.

The phone is ringing.

THE PHONE IS RINGING!

I sometimes feel my heart race.  In the middle of the night.  When I get a phone call. Or during the day.  While taking a leisurely walk with my family by the lake. The sun streaming through clouds on a brisk morning, interrupted by a fall in room 36.  An abrasion.  A cardiac arrest.   One phone call on top of another,  Occasionally so many that the calls on hold are dropped.  Or not so occasionally.

During dinner.  While in the shower.  Sitting on the toilet.  Day and night. A faint pain in the ear where the blue tooth rests.  Even when it is charging on the bedside table.  A hallucination.  The feeling of something that is no longer there.  Of something that is undeniably no longer there.

The vexing confusion on the other side of the line when I answer professionally, and the call is personal.  An even greater confusion when I answer personally, and the call is professional.  Straining to hear life altering results in a crowded restaurant.  Above the raucous sounds of my frolicking children.  In the car when the light is changing.  

A bad connection.  The basement where there is never reception. At the car wash when the blue tooth flips from my ear to the car, giving the employees an unexpected treat.  Or the waiter who stammers through my conversation concerning constipation, or blood in the stool, or foul smelling urine.  To return to ordering a hamburger, after telling a family member that their loved one has just died.

Upon realizing a few minutes after being woken unexpectedly in the middle of the night, that a pertinent detail was missed.  Waiting several minutes to get the nurse back onto the phone.  And languishing the next few hours restless. despite great fatigue, because now the mind has started spinning uncontrollably.

Distracted conversations with my wife.  Consistently interrupted.  By a patient's emergency.

The ire I feel receiving yet another text.  To only discover.  That it is just my precious daughter.

Telling me she loves me.

In the middle of a blog post...

Five Moments-Coming Soon

I Don't Understand Burnout

I have a confession to make.  I don't understand the concept of burnout.  I mean, I get the idea.  Medicine is, at least when you are the kind of doctor who deals with life and death, inherently stressful.  And I feel the stress.  It's as if someone applied a vice grip to my insides in the middle of medical school, and it has never let up since.  The pressure is unrelenting, progressive, and downright painful.  It has gotten worse with every successive career milestone.

Brutal.  It's brutal.  I new it would be after a few weeks of rotations on the medical wards.  The more responsibility I gained, the worse it got.  And I guess I entered the profession knowing this.  There was no expectation of reprieve.  No belief that I would be let off the hook.  I assumed that it was my cross to bear, my burden to shoulder.  As the burden became heavier, I learned how to amble through hospital halls with a stooped posture.

I just don't know if it could be any other way.  I can think of no relief from the burden of making life and death decisions.  What we do.  What we do matters.  A wrong turn, a flip on the ideological scale, can have devastating consequences for those we care for.  There is no escaping this responsibility.  No blunting the effect.  You can't go half way. You can't stand in the middle of the road.  You either make definitive decisions with definitive consequences or you get out of the business.  There is no such thing as sleeping peacefully for a physician.

So why are doctors committing suicide? Why are doctors leaving medicine in droves?  It's not burnout.  A small part of the reason is wrong career choice.  A young doctor realizes quickly that they didn't know what they were signing up for.

For the rest, it's external.  It's not the stress of caring for people or even making life and death decisions.  This is part of our genetic makeup.  Part of our training.

It's everything else.  It's the paperwork.  It's the meaningless paperwork.  It's the droves of administrators and clerical staff thwarting us at every turn.  It's the government and endless regulations, and rules, and threats.  It's the loss of respect, loss of standing, and loss of confidence that we feel everyday from our community.  It's economic distress.

We won't fix this by training our young people about burnout or haranguing them with some odd belief in resilience.  They made it through medical school, they already are resilient.

You want doctors to be doctors again?  You want us to love our jobs again?

Simple.  Get out of the way.

And let us do what we were trained to do.

Juxtaposition

My son,

You will face this.  You will stand at the crossroads of skill and preparedness.  Although your heart may tremble, your hands will be still.  Although your thoughts may race, your mind will be firm.  Each one of us must enter the coliseum unadorned from time to time.  Over and over again, we do battle.  Skill and knowledge spring forth from failure, not success.

I can help prepare you for this moment.  I can congeal my accrued wisdom into consumable morsels for you to chew.  I can arm you with knowledge and skill.  But I cannot do battle for you.  Not this time.  I will bring you to the trough, but now you must drink.

Drink from the well of fear and incertaintude.   Imbibe from the ocean of insecurity.  Place your head forward and savor both the bitter and sweet,

For you will be tested.  Again and again.  There are times when you will be ready, and times when you will not.  But there is strength deep down inside of you.  A voice that will lead the way.  Listen to that voice.  Follow its dictates.  Let your mind and heart propel you together.

You must become the clearest when you are down.  It is when you are most beleaguered, that wisdom dribbles in.  Be open to it.  Watch for it in the deepest pits of despair.  It will be you ladder.  It will be you life raft.

And you will succeed.  Maybe not this time.  Maybe not the next.  But eventually.

So, my son, I want you to go to school today and rip that math test apart.  I'll be thinking of you.

Thanks dad, I will.  No biggie.  

I hope your day at work is okay too.  

Hope none of the sick people die!

How the patient ends up on the wrong end of the stick

It would never have gone down this way ten years ago when length of stay was all the buzz.  The Cat Scan would have been done in the emergency department, and the patient would either have been discharged or admitted for a a quick observation stay.  Bing, bang, boom. One, two three.

Instead, the CT was pushed until morning.  A resident saw the patient at midnight and then not a single practitioner note in the EMR for nearly eighteen hours.  The hospitalist eventually deferred on the scan and called for a consult, which was scheduled for the next day because of the late hour.

After a busy day of surgery, the specialist showed up at 8pm and OK'ed the patient for discharge without any further studies.  But it was almost midnight, better to wait till the next day.  The social worker, in meetings all morning, didn't get the paperwork out to the nursing home till mid afternoon.  The nursing home accepted the patient, but only if delayed once more night due to poor staffing.

In all, the patient endured four days in the hospital without a significant diagnostic nor therapeutic intervention. He did, however, sustain a third degree decuibitious ulcer which would take weeks of wound care to heal.

I'm not sure when exactly the length of stay vs hospital readmission switch flipped.  I have a sneaking suspicion that with all this talk of readmission rates, the focus and priority of the hospitals and their hospitalist programs have changed.  Once again we have traded one slave master for another with untold and often unstudied consequences.  Don't be too hasty to discharge, we are told, you wouldn't want the patient to bounce back.  

This dance we dance with Medicare is complicated,  The incentive game sounds straight forward, but often is not.  While the hospital or doctor may be the recipient of all the carrots, the patient often finds themselves on the wrong end of the stick.

These are grand experiments we are forcing on our patients.  Unproven and untested, we must be aware that in the name of quality, we may be undoing much good.

Turned Away

Too many times I feel 
We are losing time once shared 
And only when you're in ecstasy 
You seem to really care

I recognize the song immediately.  Chuckii Booker.  Turned Away.  Not the regular version, but the extended.  As the words rush over me, caressing my nostalgia, a memory, a moment comes back.  

I was standing behind the counter at Homer's Ice Cream on a brilliant summer morning before the doors opened.  We were setting up.  One of the managers turned the volume up, and the radio blared through the speakers. The shades had been pulled back from the storefront windows, and light streamed through the door and onto the wooden tables in the adjacent dining area.  A veteran, the summer year before college, I had mastered almost every job in the restaurant.  Served ice cream.  Fry maker.  Head grill master during rush hour. I inspected almost every inch of the building.  Polished every spot.  Cleaned the bathrooms and emptied the dreaded metal containers found only in the girl's room.

My collared work shirt held the italics Homer's logo in red over the breast.  I rolled the sleeves up and squared them off above the biceps.  I like to envision my arms bulging with arteries popping at just the right places.  There was a pull-up bar in the storage room, and we often ran back if we saw a pretty girl approaching.  Quickly, we would squeeze out a few reps before returning to the front with sweat falling from our brow.   

There were all sorts of other hijinks.  I was seventeen and unsure of myself.  My heart had been broken already once or twice.  So I acted out.  Had shake eating contests when the manager was otherwise occupied.  Gave away free food to my friends, only to find that it was deducted from my paycheck weeks later.  I caroused with my fellow employees, many of them older than I, in search of alcohol and adventure.  We broke the law occasionally; got caught from time to time.  

It was all an act.  Artificial bombast to divert from insecurity.  At the time, the lyrics stung, but were an anthem played over a killer track.

Turned away.  Turned away.  Why did you have to turn away?  Turned away from love.

Like so many young people, I was convinced that I was unloveable.  I ached for a idealized connection.  A connection that both I and the objects of my affection were too immature to grasp.  Surrounded by a family that adored me, I moped at home day after day both dreading and hopeful for my upcoming departure to college.  

Those words, that tune, stuck with me.  Long after I had successful relationships and realized that I was worthy of love.  Even after I got married and had children.  

Those words still move me.  My body still sways back and forth and I feel both the pain and joy.  

And my children mope around the house much as I had.  Younger than I was at the time, but no less struggling to find their way through a confusing and cold world.  

I turn the radio up and let the words spray from the speakers and drip onto their growing bodies.  

We dance around the room with complete abandon,

and I momentarily believe that everything will be okay.  

Opt Out

If you are planning on complying with MACRA, make sure to allot the appropriate time and funding necessary to update/upgrade your practice.  Realize that the measures will be arbitrary, the data implementation arduous, and the moments for live patient care fleeting.  Expect that no matter how Herculean the task may be, the finish line will move often and unexpectedly.  Prepare to get discouraged when your software needs to be updated, maybe every year, at a cost. At least someone will be profiting from all this wheel spinning.

Check, double check, triple check the data.  There will be a host of governmental administrators waiting to disqualify your practice based on technicality.  Dot all the i's, cross all the t's.  Remember that somewhere out there is a person whose sole purpose is to find error in your work and punish you. Their bonus depends on it.

Above all, don't forget that it is your patients that are most important.  All these extra hours and dollars won't make a spit of difference in their well being.   So you may want to squirrel away more personal time to do what you used to do all day long, before you agreed to these fanciful rules and regulations

Best of luck,

If you are planning to join an ACO or Medical Home, consider hiring more staff to manage the extra burden.  What with the health coaches and life experts, it is guaranteed your payroll will swell.  When not conducting team huddles and combing the data for trendspotting, you, of course, will get back to the business of helping patients with those burdensome medical problems.  You might feel the urge to expand to cover increased costs, but in reality you will be pushed to have smaller panels and see people less often.  Why have a billable visit to a physician when the government can get off cheap by using a coach instead?  They should be able to handle heart failure, right?

The bonus payments will cover the shortfall.  At least fifty percent.  The first year.  Until the requirements get harder,

But it's all for the greater good.

So you'll work it out somehow.

If your goal is to sell your practice to a big medical group, congratulations.  Don't expect to receive more than pennies on the dollar.  The days of getting a fair market value are long gone.  There are federal regulations, you know? You wouldn't want to be accused of inducement.  I'm sure the transition will be flawless and your salary guaranteed.  For a time.

You might get to keep that favorite nurse or secretary.  Much everything else will change though.  Your medical record, your hours, your payer mix.  You will work more, for less pay, and lose much control over your day to day activities.  At some point you may realize that all that money you are making for the practice is now going to some administrator or another.  Definitely not to you.

At least someone else will have to worry about all those details you loathed so much.  You are paying them to.

If you are working towards completing your maintenance of certification activities for the ABIM...

Wait.  Wait.  Does this all sound fairly miserable to you?  It does to me.   So do something!

Opt Out.

I'm not talking about filling out a silly form and sending it to the government (although that sometimes works too).

Remove yourself from the abuse.  Extirpate your income from Medicare and insurance companies.  It's more possible than you think.  There are at least a hundred different ways to do this.

I'm doing five of them right now.

Are you going to role over and play dead?

Or are you going to do something?

A Stitch in Time

At first I thought the beeping was coming from the television.  I had just settled back into the couch after tucking my daughter into bed for the second time.  Her tummy was hurting.  It had been doing that a lot lately.  Especially on Sunday nights with the specter of Monday morning looming large.  She was getting headaches, stomachaches, nausea.  It had been going on for some time.

My son is similar.  His headaches and bellyaches come and go.  He is famous for vomiting at any given moment and then feeling fine the next.  And to think of it, we have all been under the weather lately.  Our house, as so many, has been caught up in the hacking, runny nose, sore throat plague making its way though our neighborhood.  Katie was lethargic and had a headache almost everyday last week.

We were all coping though.  Getting better slowly as the body is wont to do.  There were no emergency room visits or trips to the pediatrician.  But we were all tired after a busy week and a hectic weekend.

So when the incessant beeping started, the first thing Katie did was turn down the volume on the TV.  When it stubbornly persisted, I grumpily made my way down to the basement to investigate the culprit.  Once in the basement, I tried to triangulate from which hidden corner the beeping was coming from.  The boiler?  The water heater?  The fire alarm? The beeping no longer felt benign as I held my fingers to my ears to keep from permanent hearing damage.  It was about when I focused on the CO sensor, that Katie called down to me.

It was the alarm company.  Our Carbon Monoxide levels were too high, and they called the fire department.  I rushed up the stairs, opened the house doors, and we gathered the children and coats.  Katie and the kids waited in the car, and I went to the front of the house and flagged down the fire truck.

It was not a false alarm.  The Carbon Monoxide level in our basement was 108 PPM.  According to the paramedic, one can survive in this range for about 10 to 15 minutes.  Katie's office was the next highest at 40 PPM (it usually takes about 8 hours for a person to be overcome at these levels).  The kids bedrooms were in the 30's.

The Firemen shut down the boiler and the water heater and opened all the windows.  Within minutes the levels had fallen to zero. We slept last night in a chilly home using our backup heating system that is meant for only half the house.  Slept is a loose term, I mostly tossed and turned.  We will see if the headaches and nausea disappear.

It's disturbing to think of all the possible scenarios that could have played out without the benefit of that CO detector.

Did I mention that we just installed it a few months ago?