Thursday, May 26, 2011

On Being a Father

There was a time. In my youth. When I was confident and stood boldly in front of the fear and tyranny of longevity. And I stared down death. Without wincing. And proclaimed my superiority. Because I felt as If I had accomplished enough. I can still hear the the immaturity and naivete in my voice...If I were to die it would be OK.

And then I got married. And all of the sudden there was this other being. Who I depended on....who depended on me. And I was no longer so loose with my own mortality. For death then became an enemy. Not a raving lunatic scratching at your front door but more the lurking phantom in poorly lit allies and quiet corridors. And yet I still heard that calming voice....If I were to die today...If she were to die....things would be OK.

And then I had children. And I spent countless nights awake worrying...and holding...and comforting. These children, a product of my own creation, grew and flowered before my eyes. They developed souls and personalities. We laughed together...they jumped into my arms when they were hurt.

And I felt content. Or at least for a moment. Until the specter of death reared its ugly head again. Not as a concrete concept but more of an abstract. A what if. My previously conquered opponent was back and had a new weapon. My Achilles heal.

Those sweet beautiful children. My life's work wrapped into those little needy hands and feet. How can I now live in a world that could threaten them..that could threaten me. Because when you have children you are turned inside out. You expose yourself to the barest most sensitive parts. A million nerve endings clumped together into the small space of a fingertip.

My confidence is gone. My acceptance of life's trivialities and foibles and the fecundity of mortality have overwhelmed me. I am despondent. Torn between the utter joy and uncontrollable fear of being a father. If I my father did....It is no longer OK. And if something were to happen to my children......

See that's the thing about becoming a parent. You give up everything. your heart...your soul.

I will never be completely at peace again.

And in my new new reality

That...that is what has become OK.

Monday, May 16, 2011

I'm Coming Home

As the door opened the look on her face was undeniable. Grief. Pain. the tears rolled down her eyes. She let me into her small dorm room and hugged me. And then she told me that her grandmother was dead.

She was a mess. Her sadness was overwhelming. She sat on her bed in a stupor. And I sat with her. Holding her hand. Not saying a word. Just being.

I sat a few minutes minutes. I sat for hours. At two in the morning I returned to my room and went to bed. I cleared my books and climbed under the covers. And for a moment a worried thought crossed my mind.

I wouldn't be prepared for my exam the next day. The last few hours were supposed to be devoted to studying. Instead life had interrupted. Not my own...but a dear friends.

I sleepily took the exam the next day. One of two exams for the whole semester. And I did terribly.

It was my worst grade in all of college. My one blemish in my perfect medical school application. But it was OK. I really didn't think much of it. Back then I was that kind of person.

As I was rounding this morning in the hospital this memory came back to me. I had just left the room of a patient who was recovering from recent surgery. Although the last few days had been fraught with difficulty...she was finally turning the corner. I had assured her that medically nothing needed to be done. Just time...optimism...and hard work. She replied..."I know Doctor somehow always have a way of making me feel better!".

Now sitting at my computer I am thinking a lot about this interaction. Because strangely...undeniabley...what I have done most for this patient has nothing to do with my medical training. I have not diagnosed any disease nor rendered any life saving treatment. I have delivered basic humanity...kindness..reassuramce. Dare I say love? It feels similar to that late night in the dorm room holding my friend's hand. Telling her that everything would be OK.

This humanity...this something that almost feels like a long lost friend. Before medical school. Before my brain became clouded with algorithms and formulations. I was just a plain human being. Struggling against a cold, lonely world by practicing basic kindness. Delving into the human morass to connect with my fellow man.

But something happened to this humanity. Maybe it was the staunch self preserverance brought on by medical training or the selfishness of young adulthood and building a career and family. I somehow became a shell of the person I used to be.

Or maybe there is something about medicine. When you get paid to be a healer...a supporter of life...maybe you lose the innate drive to connect outside of your professional life. Maybe when you become an expert at being there for people, your generosity is most at risk. After all, generosity is often defined by the absence of obligation.

I once wrote a story about a father who had to go to extraordinary lengths to save his child. In the end his son dies anyway. In conclusion I wrote:

even those who walk on water occasionally find themselves stranded in the middle of the ocean. It was time to grow up. He could either let his sadness drown him or he could learn how to swim. So Derek abandoned his superhuman qualities......

and dove into the murky abyss

As the protagonist in the story maybe I also have to abandon the physician's super human qualities. Maybe it's time that I dove into the murky human abyss and returned to the generosity of spirit that led me on this life path in the first place.

Maybe it's time that I returned to the beginning.

Back to the person I used to be...

I'm coming home.

Saturday, May 14, 2011

Dear Mr. President

Dear Mr. President,

I know that over there in Washington you are surrounded by countless health care experts, gurus, academic and nonpracticing physicians. I know that you have had your fill of opinions from almost everybody...but I was hoping to add in just one more. You know...the opinion of the lowly primary care doctor in a small private practice. The kind of doctor that at one time made up a majority of the physicians in the United States. I know I am still quite young...but maybe I have became the dinosaur. Either kind will be extinct soon.

We hear from the media and the government all the countless benefits of health care reform. I thought you might want to know what is actually happening on the ground. To those working in the trenches and providing the actual health care.

Profound changes are afoot. You have revolutionized health care. And I hear you. I know you want to beef up primary care. How important you have told us it is. I even enjoyed my frst 10 percent bonus check recently. Well actually 8 percent (after you cut out co pays, and secondaries, etc). Well actually more like 5 percent if you include medicare hospital work for which we don't receive the bonus.

But I think you ought to a practicing primary care job is actually getting harder since the changes. Less enjoyable. More full of paperwork. Maybe I can provide a few examples.

Medicare came up with the brilliant idea to cut down on home health fraud by making sure that each patient needs a documented face to face visit and a physician to sign off before home health is provided. This is great. Save money. But did you ever think about who would have to fill out all these forms?

Yes each form only takes about 1-2 minutes. Doesn't sound like much. But when you do this day to day over thousands of patients it gets tiring. Just added work. It's great that you want to cut down on fraud. But why do I have to be your police force? Why do I have to use uncompensated time to do your dirty work? You know the specialists won't fill these forms out...they turf it to the good old primary care doc. I know what your saying now....well you get to bill for the visit. But I was seeing those patent's anyway. If they were sick enough to need home health likely I had seen them in the office/hospital/nursing home in the last few days already. More paperwork. More time. More hassles.

And lets hear it for EMR's. Your incentives to get them up and running is great. In fact over the last few years we have payed over 100k to have ours implemented. Recently my company misys/allscripts has written us that for only 15k more we can be prepared for meaningful use. should be easy if I get that incentive payment from the government to pay for that investment. Never mind that I already spent 100k in the first place. Never mind that if this is anything like the pqri program only 50 percent who try for it will actually get payed (and then what a colossal waste of money if I don't make it). Never mind that to read through the meaningful use criteria and fully understand it will either take a large investment of time (hundreds of pages of minutia) or an expensive consultant to actually use the system meaningfully.

Speaking of EMR's my hospital has been on the forefront of implementation. I have been using Epic for years. The quality Guru's now tell us that med reconciliation is by far worth the bang for the buck. So our hospital has now implemented a new med reconciliation tool. This will help the hospital track such important quality indicators such as "aspirin use at discharge for cad patients", "or smoking cessation counseling". This is wonderful. In concept. In reality now I have to fill out three forms as opposed to one when I discharge a patient. Med reconciliation adds 5-10 minutes to my discharge process. No problem...unless you are trying to discharge 3-4 patients at once. I have even seen less scrupulous physicians...especially when covering for a partner...keep a patient an extra day just so they wouldn't get stuck with the laborious discharge paperwork.

And by the way...the specialists are getting incredibly good at handing off the extra work. I got a call yesterday from one o the floor nurses. Dr. X says that his uncomplicated elective post op hip replacement is OK to leave the hospital and go to the SNF. "He is asking that you do the med reconciliation, discharge instructions, and COC form...his PA says they are not qualified to do this paperwork."

Then don't forget the new rules on narcotic prescriptions and hand written scripts....boy this has made taking care of nursing home patients fun!

I could continue with more examples.

In the near future I will likely have my rates from medicare cut significantly for eperscribe, pqri, meaningful use...the list go on and on. Some of these initiatives I will be able to comply with. Others I won't. My bet is that even if I try I will be found non compliant by medicare for one reason or another and not get my incentive bonus. Each of these incentives will cost money and precious time to implement. Time taken away from patient care. What medicare giveth (a 10 percent bonus in primary care) it will find another means to taketh away (pqri, eperscribe, meaningful use).

I think I speak for a large portion of primary care physicians in saying that what we see coming from ACA and the government scares the heck out of us. Already our work loads are increasing. Already we are being pushed to do even less hands on patient care and even more laborious paperwork.

I became a physician to help people...not to do paperwork...not to do community health....not to become the read headed step child of medicine. Just me and the patient. My ears, my hands, my pen.

Most of the people excited about health care reform are the ones who don't actually practice it day to day. Administrators, politicians, academicians, consultants, medical students, public health experts. They don't have to walk a milke in my shoes.

When medical students ask me about my choice of speciality I is the most rewarding field...but I certainly would have never chosen it knowing what I know today.

When my children ask...I exhort them not to become a physician.

I hope this opinion finds you well and adds to the plethora of voices whispering in your ears.

Sincerely....and with profound regret

A dinosaur soon to become extinct


Monday, May 2, 2011


It takes courage:

The man slowly rubs his eyes and looks over towards his mother....She is turning restlessly. The hospital bed rails impede her as she tries to throw her legs towards the floor. Her head moves back and forth and her eyes squint towards the hallway and the pale flourescent lights. Nurses are heard scurrying towards patient rooms and a custodian absentmidedly mops the floor outside our door.

I gently coax the elderly women back into bed. She is confused. She grabs at the telemetry moniter in her gown and then thrashes wildly. I motion for her son to stand closer to form a mechanical barrier beween his mother and the floor which sits perilously yet innocently beneath her bed.

He is terrified. His mother is now a stranger. She is belligerent. Nonsensical. Agitated. She came into the hospital slightly confused. Now she is unrecognizable.

The ER physician said, "she looks ok but we better keep her overnight just to be sure". The weekend physician on call said, "labs and CT normal...she hasn't had a stroke....but lets give it one more day.

And then early Monday his great relief...I walk in. His mother had a horrible night and she appears to be in great distress. I stand above her. I listen to her lungs, her heart, and examine her belly and legs.

I clear my throat and with determination say the last thing he ever expects "you have to get her out of have to take her home." His face shows emotions he is too afraid to voice.

He has always trusted me in the past, but his mother has never been this sick. I calmy huddle with him outside the room as a CNA sits with his mother. I explain the concept of delirium. His mother, who is fairly cognizant and clear when things are going well, is not as agile when under stress. Her ninety five year old brain is not able to adapt the way it did thirty years ago. I explain that the hospital creates severe strain on the elderly. The lack of windows, the constant 24 hour lights, the frequent awakenings and being taken care of by strangers. It is highly confusing

I can see that intellectually he understands but his heart doubts. I end the conversation by saying that I am willing to wait but if she were my mother I would take her home as soon as possible.

He decides he wants her to stay one more day. I leave the floor feeling discouraged but resolved.

A few hours later I recieve a call by the nurse....the son has returned and he is ready to take his mother home. She will not stay in the hospital another night.

Three days later they come to my office for a visit. His mother is back to normal. We are joking and carrying on like regular. The crisis has passed. I pat him on the back as they leave. I can see the relief on his face. No words are necessary.

But if they had been this is what I would say:

You see...I know it takes courage. Courage to trust that when I walk in the door I have the best intentions when treating you or your family member. That I am having a good day and have thought through all the implications before I foist my opinions on you. You worry that I don't understand the profundity of the advice that I give.

But don't forget that I live day in and day out with my decisions. that I see over and over gain the consequences of the choices that I make. That I have spent innumerable nights tossing and turning. That I have mourned countless deaths and celebrated even more victories.

And I do it daily. But it never gets easier.

Strangely I understand how you feel

It takes courage for me too!