Saturday, March 30, 2013

Your Fly Is Open

There's a good deal of soul searching that takes place in the exam room.  I see every flavor of strength and ugliness of the human character, sometimes all in the same person.  This strange mix of human suffering and superlative psychodrama have an effect on a guy.  After a decade of chasing this calling (and reaching toward a new number in the tens column of my age no less), I spend a certain amount of time trying to decide who I am. 

Now, it's fairly easy to dispel of the white night thing from the beginning.  Although a doctor, I'm no angel.  At times, my patience runs short.  I have had my moments of combativeness with my colleagues and proffered many apologies.  I am human with all the trimmings that come with the scarred irregularity of humanity. 

In this, my patients and I are the same. 

It's hard enough coming to the doctor's office with one's body broken and diseased.  It takes a small part strength and a large part courage to bare one's emotions to the stranger sitting across the table.  How awkward it is to undress and slip on one of those skimpy gowns with the strings that never seem to tie appropriately in the front or back?

There is enough embarrassment.  So when a patient is dressed and the counseling is over, if I happen to notice and open fly or a shirt that is sloppily untucked in the back, I mention it.  I come right out and say it no matter how my face may flush or how awkward the following silence may be.  In fact, I do this outside the exam room too.  Because I would want someone to tell me. 

And maybe in this, I have finally found a definition that suites.

Who am I?

I'm the guy who'll tell you your fly is open.

Every time. 

Thursday, March 28, 2013

Bravery And Consequence

There's been a lot of patting on the back lately, and telling me how brave I am. 

And usually, I shrug my shoulders and bask in the glow of approval.

Lately, however, I feel more like a coward.  I hunker down in the exam room and shield my psyche from the initial reaction.  Brows furrow and words come out faster than mouths can speak.

You're leaving the practice?

Wrinkles become smooth as I explain the new paradigm.  What's there not to like: less patients, home visits, more proactive care.  Once again my nerves unwind, yet I know the moment has come.  The tone changes as we get to the yearly fee.  While it doesn't phase some, I can see the gulf form in others.  Eyes turn dead and dart towards the ceiling, expressions become frustrated or just plain angry.  They know they're being left.

I didn't have to do it this way.  I didn't have to start this early.  I could have just kept my mouth shut and waited to send a letter.  But that wouldn't be me.

I will stand before each and every patient.  I will tell them face to face.  I will accept their reactions whether joy or disgust, because I owe it to them.

I made this decision willingly,

I won't cower from the consequences.

Tuesday, March 26, 2013

Zero Sum Game

This is what I tell my patients...

The world is changing for providers.  Heavily medicare weighted, the last few years have seen a proliferation of administrative paperwork.  When not overwhelmed with forms, we are hunched over computers inputting inane information like race and ethnicity.  What we are not doing, is taking care of patients.  We are not interfacing with those that we have sworn to care for.  The covenant I have so often written about is being replaced with vague ideas of community health and meaningful use.  In no uncertain terms, we are letting you (the patient) down.  This makes me ill.

A few months ago, I had a crisis of conscience.  I could no longer sign off on this willful subjugation of the doctor/patient relationship.  So I crunched the numbers.  What I found shocked me.  Most of the revenue from my practice comes from nursing home work.  In other words, all those hours spent in the office and the hospital did exactly one thing.  They paid the bills for that very office and all my employees. It's a zero sum game.  I would be better off economically if I finished each day at nine am in the morning.

So I decided to radically change the way I care for people.  I will continue to go to the nursing homes, but I am also opening a micro practice.  Trading in my two thousand plus patients for a few hundred.  In fact, I am mostly contemplating visiting people in their homes or places of business.  My patients will have my cell phone number and email address.  When they call the office they will get me, not some nameless, faceless employee. Care will be more proactive and patient centric.  Technology like skype and face time will bridge the gap.  I will once again be able to devote the time and energy necessary for every single soul under my care.  I will still be forced to do paperwork, but when your patient load is a tenth of the size, the time consumed is much less significant. 

Of course, there are drawbacks.  To support this micro practice I will charge a yearly fee that is not payed for by medicare or private insurance.  This fee will subsidize all those individualized services not covered by traditional models.  The doctors in my area generally charge X for this type of service.  I will also charge X, but I will see you in your home or place of business instead of the office. 

In a few months, you will receive a letter in the mail outlining the details of my venture.  I invite you in joining me in a revolutionary and patient centered model of health care.  For those who decide not to follow me in my future pursuits, your medical records will remain here and one of the doctors in the office will be happy to pick you up as a new patient.

Thank you for placing your trust in me.

Saturday, March 23, 2013

Death Is Often Quiet

It is one of the most difficult things for lay people to understand.

Usually there is a moment to collect my thoughts as the phone rings.  I speak slowly and deliberately.

Something has changed.

They are carefully chosen words to cushion the unavoidable plunge into darkness.  I know. I know. 

It happens dozens of times a year.  Death follows me home after a hard day of work.  It buzzes against my skin and awakens me from a deep sleep.  It yanks me out of exam rooms and interrupts family dinners.

Such irony for a boy excused from class in second grade to be accompanied home by a family friend.  My mother pulled me in close and whispered that my father was gone, even as relatives sat in the living room glumly.  But now I have become my mother and guide families through this awful blackness. 

I wonder how it affects me.  While others struggle with shadows, I see quite clearly.  My eyes have adapted so expertly that often I feign empathy as friends relate the tragedies of the day.

I didn't know my career would lead here.  I didn't know that I would be good at it.

I pray, my dear reader, never to meet you in this lonely place roaming beside me.  But, if I do, I might offer a bit of wisdom.

Death is often quiet.

Pain should be the exception, not the rule.

And suffering, it turns out, is mostly left for those who remain.

Friday, March 22, 2013

My Interview With Mike Sevilla

If you have some extra time, listen to my interview with Mike Sevilla on Blog talk radio here (1 hour interview).

Or for a short clip at the end of the show go here.

Tuesday, March 19, 2013

Will They Follow?

It hurt, more than I was ready to admit at the time.

John walked into my office years ago with a stack of papers under his arm.  A few hundred pages to be more exact.  He carried his copy of the medical history like a burden that was more a part of his body than a separate, distinct object.  He pushed it forward onto my desk tentatively. 

There was the usual minutia of any medical record: labs, injections, consult notes. It was a cat scan, buried under reams of repetitive nonsense,  that caught my eye.  The little smudge noticed by the radiologist was a nothing, a ditzel.  But there was no followup.  No further workup.

Originally John was alarmed, then scared.  The biopsy showed a lethal malignancy if left untreated.  I put my arm around his shoulder as he shook.  A week later he underwent a successful surgery and was cured. 

For years he walked in and out of my office on a regular basis.  I was the doctor who saved his life, and he was my patient.  In 2007, I announced that I was moving my practice thirty minutes to the north.  Of all the people, I was shocked to find that John refused to follow.  Without apology, he explained that he preferred someone closer. 

My sense of professional worth dropped a notch that day.

Now, in 2013, I am again asking my patients to make a drastic change. Although I have had nothing but positive feedback, I can't help but feel a tad skittish. 

I will stand alone, exposed, and make my pitch.

But will they follow?

Saturday, March 16, 2013

Doctoring Is An Act Of Love

As any well cared for patient will tell you, doctoring is an act of love, not a job. 

In what other relationship do we directly put ourselves in a position of long term responsibility regarding others physical and emotional well being: parents, children, spouse, good friends? 

This covenant has it's privileges.  You become a grain in the sand of people's lives.  Membership is deep and enduring.  Very few are lucky enough to wake up every morning with a sense of meaning and purpose.  In the end, this is what drives people to the profession.  No amount of money, power, or ease can replace human connectedness.

But it's hard.  Not hard like bench pressing two hundred pounds.  Hard like carrying a sand bag on your shoulders for the rest of your life.  Your neck often bends and your posture stoops forward.  When a patient is lost, one would think that the burden is lightened, usually the opposite is true.  And there are always new patients requiring you to forfeit a small part of yourself.

There is often less to go around for others.  Your family and friends, your children, sometimes only get the scraps.  The pieces are what's left at the end of the day.  Your loved ones have also unwittingly made a covenant with every patient that walks through your door. 

If you understand this.  If you see this.  Then it is no great surprise the turbulence most physicians are now feeling.

The filling of forms.  The clicking of clicks.  The reams of checklists, rules and regulations. 

It's turning this great act of love into a job.

A clerical, emotionless, empty job.  

Tuesday, March 12, 2013

The Infestation

In my area, the infestation begins every winter around now.  Usually it's ladybugs.  They mercilessly paw through the porous innards of the house.  They crawl on the floor, bed, and drapes. Once I used a vacuum cleaner to suck dozens only to find many more waiting around the corner.  As the weather warms, and spring moves into summer, there is a much welcomed reprieve.

This year is different.  The ladybugs have been replaced with a much darker menace.  Black, beadle like creatures with wings, now whiz by my face and land on the windowsill. They are truly ugly.

At first, being a kind and gentle man, I lifted the creatures off the carpet and released them gingerly back into the wild.  The kids jumped and cheered as they waved goodbye from the back door.  But patience and repetition are poor bedfellows.  Before long, I became used to the crackle of exoskeleton between my fingers unhindered by the burial shroud of protective tissue.

Mocking revenge followed quickly. Upon turning on my bedroom light each evening, I would be greeted by multiple carcasses of emaciated beasts searching for their last morsel on my hardwood floors.  My daughter, squeamish as can be, began to scream every time one of these depraved insects crossed her path.  I would run into her room in a panic to find not a bloodied bruised child but a small dark nemesis laughing at my overwrought imagination.

Sometimes I dream that I lay paralyzed in bed as an army of small legs and wings overtake me .  They cover my skin. Even though I want to swat them, I have lost the will.  They peck away at my dignity but stop before the point of real harm. 

I am beaten.

This is what it feels like to deal with Medicare lately.

Saturday, March 9, 2013

The Customer Is Always Right

You get to know people after a few days in paradise, sitting on lawn chairs in front of the pool.  You talk about where your from and your kids (if you have them).  You might spout off about your job or friends.  These are the pleasant conversations exchanged between vacationing strangers. 

You may learn that one of them has taken ill: woken up per chance on a beautiful idyllic morning with a sore throat and pressure under the cheeks.  Luckily, among the charming amenities of such brilliant resorts, is a doctor on site.  As a physician yourself, you may role your eyes as they describe how the doctor proclaimed sinusitis and ordered an antibiotic.  Not what you would do, is it?  Antibiotics are not necessary for acute sinusitis of short duration, are they?

But then again, resorts are not about making sound medical decisions.  Resorts are about keeping the customer happy.  Do they check one's cholesterol before serving the fatty fillet for dinner?  Does the poolside bar measure blood alcohol levels before serving a drink?

No, of course not.  That business would go under in milliseconds. It is not their job to keep their patrons healthy, it's to keep them happy.  No one is silly to mince these principals. 

Our medical system, on the other hand, is about making people healthy.  Only the most obtuse would also consider it about making people happy.  In fact, often medical practitioners deal with decisions counter to patients happiness.  We tell them to stop eating those sweets they love.  We rip the cigarettes out of their mouths.  And yes, we deny antibiotics when they are unnecessary, no matter how bad we are begged for them. 

We are not in the resort business.  We should not be judged the same.

Patient satisfaction is not a measure of quality.  It's a measure of customer service.  Except in our business, the customer is not always right.

Don't make us give poor medical care by penalizing the strength it takes to give an honest opinion.

What happens if you act like a schmuck and treat your patients poorly?  They vote with their feet. 

That is the most rational satisfaction score around. 

Wednesday, March 6, 2013

Attention Technologists, CEOs, And Health Care Consultants

The ICU hummed as the tech guy waltzed in at two in the morning.  A key designer of the EMR himself, the night shift nurses had his mobile and were not afraid to use it.  There was a problem reconciling Mr. Jones med list after his emergency bypass surgery that evening.  Patients first.

The next one in the door was the young CEO of the hospital.  A firebrand, he had pushed the ACO envelope to near completion.  There were still bugs, and no primary team was yet claiming Mr. Jones as their patient.  Some things need to be sorted out in person, even in the middle of the night. 

The chief quality officer was following close behind.  There was a new initiative to interview the patient or family within four hours of admission.  Of course, Mr Jones came in at midnight and was whisked off to surgery immediately.  Some one had to find his wife.  The clock was ticking.

Nowhere, I repeat, nowhere was the surgeon.  After the quickie procedure, he must have been in the middle of a catnap.


As ludicrous as it sounds, I think we often forget what taking care of patients really looks like.  Before we write off physicians for being Luddites for their slow adaption of all that is changing in health care, I think we need to take a closer, harsher look. 

Attention technologists, CEO's, and health care consultants: your decisions can be as dangerous as a nurse with a syringe of overconcentrated heparin, a surgeon with a lack of appropriate sleep, or an internist with the wrong diagnosis.  Yes, your actions can kill!

When EMRs are implemented that take physicians eyes and minds away from the patient without demonstrable improvement in quality of care (and cause excess spending), patients can die.  When four hour pneumonia rules are followed with no scientific evidence, certain patients get C Diff and end up in the ICU unnecessarily.  And when inane unproven giants like ACOs are forced on a population, who knows the untold irreparable harm can be done.

For too long, doctors have been on the front lines taking the responsibility for every aspect of patient well being.  And justifiably, we have become quite cautious.  We don't like following dictates unless a modicum of evidence suggests benefit.  We make decisions based on years of training, reading, and personal experience.  We do not implement new care policy because it "sounds right" or "makes sense".  We have been burned too often by such simpleton principles. 

Yet over and over again, physicians are blamed as slow adaptors and the reason why new policy fails.  If only doctors would fall in line like good soldiers.

Follow me.  Follow me into exam rooms with hobbled patients and hopeful expectations.  Follow me into hospital corridors where families huddle desperately over prayer books and rosary beads.  Look these people in the eyes.  Tell them that you will take responsibility for your actions whether their loved ones live or die.

Then and only then. 

Feel free to criticize me.

Sunday, March 3, 2013

Just Sayin

We have to stop comparing ourselves to the airline industry.

Sitting on the lounge chair at the pool, I can't believe that just hours ago I was sludging the wintry streets of Chicago, rushing to the airport.  The kids clucked away happily in the back seat as the adults in front where more subdued.  As grownups do, we kept running through our mental checklists even though the ship had already sailed, we left the house.

The trip, in general, was quite smooth.  With the exception of seating.  For some reason, even though we had made the reservation months in advance, the four of us were sitting in completely different rows.  Now, although I miss my wife dearly even when the separation is just for four short hours, for the little ones sitting by themselves just wouldn't suffice.

At the baggage check in, the clerk said there was nothing she could do and asked us to wait until we arrived at the gate.  At the gate, they blamed the airlines new computer system and unsuccessfully tried to convince other passengers to switch seats with us.  They refused.

While boarding the plain, I really started to wonder why we in the medical industry want to model ourselves so badly to the airlines.  There are so many things the flight industry gets wrong.

Let's think about this.  How often do flights run on time?  How often are flights cancelled?  Why is it that baggage gets lost on a regular basis?  Why was it so hard to seat me with my young needy children?

The truth is, there are problems so complex that even the airline industry can't solve them.  Sometimes, no one can predict how a cold front over the Atlantic will affect an intricate and interchanging landscape of schedules.  Things get lost, there is human variability and error.  And new computer systems sometimes aren't programed how they should be, or the end user is not trained to use them correctly. 

What becomes ultimately clear, is that human beings especially, do not follow a manual. The number of interconnecting parts are too great.  The whim of human frailty is largely a mystery.

So there are successes.  Airlines are great at making checklists for highly controlled situations where mechanical failures occur in flight.  These failures are knowable, predictable, and often amenable to corrective measures.  I would say that the medical field of anesthesia (also a highly technical field) has had similar success.  But for most other types of medical practice, as well as for the airline industry, we are plain lousy at dealing with the incredibly complex field of human (and climate) diversity.

When we finally got to our seats, a courageous young man looked at the four of us, and willingly moved so a mother could sit with her young children.  After all that wrangling, the answer became obviously clear when the involved parties were face to face with the reality of the situation.

Oh, and by the way, medicine is nothing like the Cheesecake Factory either.

Just sayin!