Saturday, December 20, 2008

The Day I Lost My Confidence

I brace as the sheets of white assault my car. My foot on the clutch sways with each loss of traction. The clock reads 5:30 or some ungodly hour. The roads are empty except f0r the occasional companion that passes in the early morning darkness. My mind is distracted. The forecast is bleak. Snow all day. The department of streets and sanitation has released a travel warning and suggests staying off the roads.

Why not work from home? Call into the office? Not exactly an option for a physician. The patients in the hospital can't be cancelled. I can't just wait to see them the next day. And then there's the expectation. That I will be available. Even on the worst of days. I'll be there...Just call. I'm not sure if the unreasonableness is theirs or mine.

And my brain races back. To a year ago. On a morning like this. Before the snow plows. Hurrying to make it to the hospital for who knows what. Just a few blocks from the office. On the expressway. When I lost control I thought I was going to crash into the barrier. But then to my complete horror the car skidded in the opposite direction. I had just moments to contemplate before I hit the semi. Luckily in the back. And then I swayed to safety to the side of the road.

Unscathed...physically at least. But a year later I 'm still a little skittish. Moment by moment trying to recover.....from the day I lost my confidence.

Wednesday, December 17, 2008

The Caregiver Phenomena

A thought gelled in my mind today which has been subconsciously stirring for years. I was seeing a 90 year old women who came to the office accompanied by her daughter and caregiver. She had not been feeling well for the last few weeks. She was coughing, having chest pain, and generally feeling under the weather.

The patient didn't look sick. In fact she looked pretty good. She even voiced that she felt OK. The daughter agreed that her mother was looking fine. The only one in the room who seemed in disagreement was the caregiver. The caregiver described how her charge was getting worse and failing to turn the corner. In fact I could almost predict the care giver's responses to my questions before I gave them. Basically for any open ended question there was almost always a negative response suggesting that the patient wasn't doing well.

I have known this caregiver for years. And she does a great job. Very attentive, loving, and hard working. She is present for every cough, and sneeze, and complaint. She works tirelessly long hours. So what gives? Am I and the daughter missing something significant or is the story from the caregiver not exactly accurate? And if it's not accurate then why?

While pondering this question I quickly realized that I encounter this type of behavior regularly. In fact I often find myself going to great lengths to corroborate information given from caregivers. My experience has shown that they often overstate or occasionally exaggerate their charges complaints. In the beginning of my career I took these reports literally and found myself over treating: ordering too many tests and giving too many antibiotics.

I have coined the term the caregiver phenomena to describe this type of behavior. I suspect it stems from two different causes. First, the caregiver who is not medically trained, is often present for every complaint and is afraid that something bad will happen during their watch. They are terrified of missing something significant. Second, I believe the caregiver is often the one who blows the whistle by alerting the family and thus initiates the actions that eventually lead to the doctors visit. Many caregivers feel pressure to justify the visit by making sure the doctor knows the levity of the situation.

Whatever the cause of this effect I feel that most caregivers are genuinely interested and preoccupied with performing their job well. But I now consider the caregiver phenomena when ever I interview an elderly patient.

By the way thanks to Tracy for this. Even if all my ten readers vote for me it still wouldn't be enough!

Sunday, December 14, 2008

Inside The Examining Room

The elderly gentleman limps into the examining room. His 89 years etched into his gait as if each day delivered a small but crippling blow. His callused hand grips mine briefly but with the confidence of experience.

He didn't trust me. At least not in the beginning. I could have spoken his first words before they left his lips....I generally don't like doctors. But pain is a strongly coercive force. He spent the first few visits feeling things out. But over time he learned to confide in me. And as the protective layer of fear and angst were discarded...the humanity came through.

He was having surgery. The orthopaedist had convinced him he needed a new hip. My litany of questions were usual. I left short pauses for him to answer. No chest pain. No shortness of breath. Good exercise tolerance. No tobacco. And alcohol.....I quit years ago!

His answer was unexpected. I pictured him the kind of guy who lived hard...and drank hard. A generalization.....but generalizations got your far in the doctor business. I knew I shouldn't have asked but I couldn't help why did you quite?

He took a moment to collect his thoughts.

It was the forties. I and a bunch of buddies worked for a company that put up television antennas across southern Illinois. It was the early days. A new technology. I left my wife for months at a time.

We worked all day in the sun during the summer and in the cold in the winter. They were long days. After work there wasn't much to do. We usually left early and went directly to the bar. Often not taking time to eat dinner. And we would drink. Well into the morning. Then get up a few hours later and go back to work.

It was the same thing six days a week. The same fellas. The same bar. The same drinks. I was wasting my life away but I can't say I minded. We didn't know any better. It was just what we did.

So one day I walk into the tavern in a bad mood. It was something insignificant; I can't remember why now. The owner, Charlie, was standing behind the bar in a full hunting suite. He had a brand new expensive rifle. And he was holding up a picture of a ranch. He bought it for his wife and kids.

And there I was eking out this existence. Sharing bunk bends in a dirty motel. My wife and I barley able to afford our apartment. And I was pissing away my money getting drunk. That son of a bitch... I was paying for his four star ranch and his shiny rifle.

So that was it.

That was it?.... I repeated

That was it....never took another god damn drink again!

Friday, December 12, 2008

In Memorium

My whole life I have been immersed in a world of words. Not just meaning but sounds. The cadence of a sentence. The emotion behind the basic structure. I have surrounded myself with diversity. Often associated with people who don't look like me. I grew up sitting at tables where the language spoken often wasn't my own.

It never bothered me. I would get lost in the rhythm of a foreign tongue. Picking up on the nuances and facial expressions. Missing the exact definitions but understanding the meanings. The better I knew a person the more I could piece together. There was always more in common then not. One had to look for it.

Recently I accompanied my wife and children to a relative's house to mourn the loss one who had recently departed. As we entered the women and children were directed to one location and I was shuffled off with the men to another. The room was solemn. Twenty men gathered dressed in black. Many bearded. I immediately felt a stranger in a strange land. My hand absentmindedly pawed the top of my head were the ritualistic covering was glaringly absent.

I socialized with many of these men a dozen times over the years. Separated by foreign birth and a religious orthodoxy I had never felt much kinship. American born and uninterested in religion I was more like the foreigner.

The conversation started with a deep philosophical discussion of Jewish law and culture. The Rabbi in the center of the room paused between points. Intermixing Hebrew and English. The gentleman sitting next to me noticing my discomfort whispered softly in my ear, "It is only after years of studying Jewish law that you can have such conversations!"

The words took form and shape in front of my eyes. They were no longer English and Hebrew but musical notes dancing through the air. The rise and fall with each pause as the Rabbi spoke. The room moved in unity. Chests filled with air and then exhaled. Release and expand. Release and expand.

Yit'gadal v'yit'kadash sh'mei raba....

The men of the room had now stood and were reciting the Mourner's Kaddish or Jewish Prayer For the Dead. And suddenly I was transported back to childhood. My mother, brothers, and I are in temple. It is my father's yahrtzeit (anniversary of his death). I must be about ten years old. Every year we made the trip to temple on this particular week.

Most days we lived our lives as if nothing happened. But on this day. We came to temple. We remembered. The service always felt unending. Standing up and sitting down. Standing up and sitting down. My brother's and I distracted ourselves the best we could. Making funny faces....playing silly games. Anything to pass the time.

But then the Rabbi would clear his throat and boom from the lectern, "And now let us remember those loved ones who have passed this week...". He then recited the mourners kaddish followed by a list of congregation members who had died. Our ears perk up and we wait to hear my father's name. And then we leave the synagogue shortly thereafter.

I awake from my reverie. the group of men have now finished praying and are chatting comfortably amongst themselves. I long to join my wife and children in the other room. I scan the faces around me. We are so different. For them, religion is their life. For me, my life is my religion. Yet it dawns on me that we share common bonds. Our words may be different but we all experience happiness and pain. We all mourn...

And when wounded we all bleed the same.

Tuesday, December 9, 2008

Some Thoughts on Quality

Recently in response to a post (somewhat tongue in cheek) about renaming primary care physicians "prehospitalists" Mathew Mintz commented:

Don't like it. Pre-hospitalist implies that everyone will eventually go to the hospital. Though we certainly do our best to prevent patients from needing hospitalization, this doesn't capture the bulk of what we do: screening, prevention, counselling, chronic disease management,etc.

Mathew's comment really made me think. While he is right....keeping people out of the hospital does not describe the bulk of what we do. He misses the point. Our ability as primary care physicians to cut down on admissions may be the single best indicator of physician quality.

The physician who keeps his patients out of the hospital probably:

Is an excellent diagnostician
Manages chronic disease states well
Is timely
Calls his patients back promptly
Likely is highly active in screening and prevention
Sees urgent appointments on the same day

The list goes on and on. Sure there has to be an adjustment for patient age, socioeconomic status, and overall health of the patient population (a clinician who treats esrd, end stage copd, end stage cad...will have a higher hospitalization rate then others).

But I like hospitalization rate as an overall indicator. It certainly is hard to game this one...unlike the other quality indicators that have been used (a1c, colonoscopies, etc.).

So what do you think?

Sunday, December 7, 2008

When Passion Meets Talent

There is a moment in some peoples lives were god given talent and passion mesh to create something beautiful and unique. Those who are lucky enough to experience this rare gift have a special power. The power to change the world.

I was born thinking medicine was my passion. From the earliest ages I can remember wanting to be a Doctor. I have no idea where it came from. I have no idea how it grew. But it was my goal. It was my dream. Most of my waking moments were consumed by it. It didn't matter that I had a learning disability. It didn't matter that I almost had to stay back a grade. All hurdles were temporary. All surpassable.

And so I spent my youth on this goal. I expended countless sums of money. Studied for hours without reprieve. Worked excessively long shifts without sleep. I did whatever it took.

And I succeeded. I finished medical school and residency and began living my dream. But something was missing. Maybe it was the paperwork. Maybe the sadness of watching people die and being helpless. Maybe the anger so commonly directed towards physicians which often felt unjustified.

Being a physician no longer ignited longer set my heart on fire. But something did. Strangely and unexpectedly it was writing. First poetry and then stories. It would wake me up in the middle of the night and force me to turn on the light and jot down a word or phrase so that I wouldn't forget in the morning. And I was least sort of.

Friday was a perfect example. In the morning waiting for me in my in basket were rejections from four publications refusing my poetry. They all came on the same day. I can't say it was unexpected. Anyone who has submitted poetry for consideration knows that rejection is just part of the process. You have to develop a thick skin they say.

So I was down as I made my way to the hospital. One of my partner's patients had been in and out of the inpatient service for months. She was a mystery. Several hospitalizations, and specialists, and cat scans later my partner still wasn't sure what to do with her. As I reviewed the data and finished my examination everything clicked. I knew that I caught something that everyone else had missed. So I made a few changes and added a key medication and within 24 hours she was better. It might take some time but I know she will recover.

On my way home yesterday it hit me like a ton of bricks. I always say that each person has a gift and if we are lucky we find it while there is still time to act. For years I have been searching for my gift. I was hoping it would be poetry. In reality it isn't. It's medicine....medicine is the one thing I am truly gifted at. Medicine is what I was meant to spend my life doing.

I am the luckiest man on earth. I have a wonderful wife and children. I have a job and enough money to live. And now I have found my calling. My one offering to humanity. But sadly....somewhere in the process after all those years of yearning, and striving, and working...I've lost my passion for it.

Gift and passion. Passion and gift. Somehow they've missed each other so far in my life. But what if....what if for just a moment I could realign them again.

Oh the the things I could accomplish!

Wednesday, December 3, 2008

The Slow Down

Its happening again. I'm entering my second year of practive in my new location. And strangely....unexpectedly...I'm finding myself not very busy. In fact if I look back at my schedule I was busier six months ago then today. This really worries me. Surely I have more patients now then I had six months ago. In fact I usually see at least one new patient every day if not 2-3. So what gives?

At first I thought maybe its just the economic slow down. Maybe people don't want to pay their copays. I guess thats possible. But at least 50 percent of my patient population is medicare. They don't have copays. Then I thought maybe people are leaving me. That I am being ineffective. But we haven't recieved any record transfer forms. In fact a number of patients have moved considerable distances but still come back in town to see me.

Now that I think about it the same thing happened in my last practice. Coming out of residency I joined an internal medicine group that I stayed at for five years. Over time I accumulated about 2000 patients and was one of the busiest doctors in the office. But the truth is....the same thing happened there also. 2-3 years into it my numbers went down. My hospital census plummeted to one patient a week (after maybe having 2-3 patients in the hospital on a given day).

So what to make of all this? Previously I made up for low numbers by covering the other docs in the office. Although I saw more patients then any of them, I also would see most of their overflow. There were 5 more senior doctors in the same office who provided a steady stream of acute visits.

In my current practice there is only one physician more senior then I. So I really don't get much overflow. I still see my partners patients in the hospital...this keeps me a little busy. And for the first time in my life I am going to nursing homes and have taken on a medical directorship.

Maybe my patients just aren't that sick. I guess thats possible...but I have a huge medicare population. In fact....occasionally I have days where I see 4-5 patients in the office on the same day who are in their nineties. One of my biggest referal sources is the local nephrology I have more then average number of dialysis patients.

I guess in my heart of hearts my hope is that I am slowing down because I am taking good care of people. Because I am catching disease earlier, treating it more aggressively, and keeping them out of the hospital. Becuase I am getting my dying patients enrolled in hospice so they can die at home.

In other words....I think my patients are needing me less and less each day. Gratifying...but bad for the bottom line.

But who knows...I could be wrong....maybe I am just pissing people off and they are leaving me!

Monday, December 1, 2008

A Dirty Rumor

There is a rumor out there. And it says that primary care practicioners are running up the cost of medicine. That they have been squeezed so tightly by busy schedules, paperwork, and short visit times that they have become careless. More on this in a moment.....But first a story.

A young lady enetered my office 6 months ago for a physicial. Among other things she was having trouble swallowing. She felt food would get stuck. She was healthy. No weight loss, her symptoms were intermittent. So I questioned her, examined her, and carefully explained my thought process. Given that there were no alarm symptoms we decided to start with an acid reducer for possible reflux and a promise that if she was no better after two weeks she would call and I would send her for a barium swallow.

Months passed and I heard nothing. Then last week she walked into my office crying. She did not try the acid reducer. Instead she went to see an ENT (Her PPO allowed her to go without a referral). The ENT did a scope and sent her to a speech therapist for a swallow evaluation. The speech therapist did a video assisted swallow study and was convinced the patient had a mass in her pharynx. She then sent the patient to another ENT. Who scoped her again and sent her for a ct of the neck. When those were both negative he scoped her one last time for God knows what reason.

So she returned to me, crying, anxious, and having even more frequent difficulty swallowing. So I again suggested an acid reducer (which she promised she would take) and an anti anxiety medication and hopefully she will see me again in a few weeks. And if that doesn't work I'll either do a barium swallow or send her to gi for an egd. The right workup that should have been done in the first place. I bet, however, she won't need it. I bet her symptoms will be gone by the next time she sees me.

So back to that rumor. You can argue that internists consult too much. That they send patients for too many tests. But as my story illustrates....specialists do the same thing. You see...good doctors treat disease expediently and cost efficiently. Bad doctors don't. It has nothing to do with a percieved time crunch. Give primary care doctors more time....the good ones will still do a good job, the bad ones will still do poorly. Period!

It's not a time issue ias much as a quality issue. The harder question is how do we reward quality!

By the way...I think PCP's could benefit from more time with each patient. I just don't think economic ramifications will be as drastic as most think.