Thursday, July 25, 2013

Mental Calculus

He would describe himself as sensitive.  Not as in a lack of confidence, but more like able to tune into the feelings of the people around him.  It is probably why he became a physician.  A lover of math, he tripped on the mental calculus.  How many wins were needed to make up for each loss? How many lives would transform a death.  Even Michael Jordan missed a shot occasionally.  You can't tell me that Babe Ruth didn't strike out from time to time. 

He liked to daydream about powerlessness.  It would be so much easier if medical science were impotent.  He then could measure his worth in the warmth of a smile or the weight of a hand resting on a tired shoulder.  These were things he could offer without risk, without opening himself up to heartbreaking failure. 

He often pictured his own death.  Others fantasized about being met at the pearly gates by people they knew who had passed on: parents, friends, or lost lovers.  But who would meet him?  He had known hundreds, if not thousands who died.  He touched the acrid flesh, over and over again, uncovering physical and emotional pain.

He wondered if there would be a calamity.  His supporters would surely welcome with open arms and kind heart.  But what about those who were not ready to die?  They may shake their fists and scowl because he had not been enough.  A sort of scuffle would break out and opposing forces would clash.  Who would win?

But this was all just a dream, a confused, paranoid dream.   In reality there was no battle of judgement, no balancing scale.  And this was his burden. This was the thing he carried on his shoulders from day to day, week to week. 

This was the thing that pulled him back, that propelled him forward. 

Wednesday, July 24, 2013

Does Ezekiel Emanuel Think We Are Weenies?

Tilburt et al published a study in JAMA this week suggesting that physicians feel that other players (lawyers, insurance companies, hospitals, etc)  are more responsible than doctors for reducing healthcare costs.  Furthermore, they are hesitant to promote reforms that eliminate the current fee for service payment system. 

Although I would bet the no one would be surprised by these findings, a scathing editorial by Ezekiel Emanuel and Andrew Steinmetz caught my eye.  Before I get to the particulars, I would like to make a few (hopefully mostly uncontested) observations.

1)Physicians are some of the most educated, hard working individuals in American society. Very few professions require a four year doctorate, plus a minimum of a 3 year apprenticeship.  After finishing our training, we have long hours, take phone calls over night, and work many weekends. 

2)People, by in large, don't go to medical school to make a fortune.  There are many other professions that are more economically worthwhile with less debt incurred. Based on the GPA requirements, these applicants could likely choose almost any profession.  Medicine is a passion and calling.  Those who do not feel so drop clinical practice fairly quickly.

3)The daily job of physicians is to investigate, consider, and choose between incredibly complex and different avenues, and then take action.  We are trained to see the subtleties in both the written word as well as during patient presentations.  This is a thinking man's sport.

So when a large majority of educated, capable, and thoughtful people proclaim an opinion, one would think it would be wise to pause, consider, and evaluate before wholeheartedly dismissing the group as a bunch of weenies.  Unfortunately, Emanuel and Steinmetz think differently.  They proclaim:

The findings of Tilburt et al. confirm this ingrained human behavior by showing that physicians are hesitant, if not unequivocally opposed, to taking bold steps to re-engineer incentives in the system -- steps that may well have the most meaningful effects on controlling costs...

I couldn't agree more. Yes, thoughtful physicians who have been led astray before, are not jumping into the arms of governmental change.  Let us ponder a few questions.

1)Have any of the finished medicare demonstration projects ever had positive results?
2)Has pay for performance in the past, on balance, shown a financial or quality of care improvement?
3)Is there any proof that ACOs or PCMHs will improve the quality or cost of care?
4)How is the government doing so far at balancing the budget in general?

As physicians we learn to use scientific evidence to support our theories.  We have been burned time and again in medicine by using logic above data.  After careful consideration, moving forward "boldly" but foolishly may do more harm then good.  Ezekiel's fantasies about healthcare are unsubstantiated.  Show us the data, and we will follow willingly.

The editorial continues:

This is a denial of responsibility...Of course, physicians do not want to be blamed for the country's major problem. But can they really be both the captain of the healthcare ship and cede responsibility for cost control to almost everyone else?   Ultimately, what this survey tells us is that physicians acknowledge that health care costs are an issue, but they are not yet willing to accept primary responsibility and take definitive action to lead change.  The rejection of transformative, bold solutions to address the seriousness of the cost problem is indicative of much bigger problems ahead of we don’t start seeing more leadership from the physician community.

It's simple.  If you want us to be captain of the ship and take on all the responsibility, then you have to actually listen to our opinions.  Rehospitalization policies, pay for performance, and meaningful use are all untested ideas that have made both our and our patients lives miserable.  EHRs have never been shown to improve quality or cost of care.  Study after study is starting to show that rehospitalization rates are extremely difficult to modify.

Most importantly, our lives as primary care physicians have deteriorated greatly in the last two years.  The amazing amount of paperwork, the denials, and the computers are sucking our attention away from real life, difficult, patient problems.  Ask any patient, they will tell you that the office environment has deteriorated.

Finally, Emanuel and Steinmetz warn:

Unless physicians want to be marginalized -- unless they are willing to become just another deckhand -- they must accept and affirm that they are responsible for controlling healthcare costs.

I guess he doesn't realize that we feel as if we have already been marginalized.  But "deckhands" we are not.  If we decide decide to jump ship, whose going to steer the boat?

Maybe Ezekial Emanuel will.

Saturday, July 20, 2013

Unlikely Miracles

We were pretty damn lucky that she was young and healthy.

The surgery had been technically successful.  I watched as the resident finished with the last sutures.  Although the attending had already left the room, I looked on with the eagerness of a third year student.  Orders were written, and the patient was transferred to recovery.

It was a routine hysterectomy.  None of the pizazz and flare of a gyne onc surgery, but at such an early stage in my career, I thought I was witnessing rocket science.  We left the OR and rounded for the rest of the afternoon.  As I hunkered in for a long evening in the hospital, I got a page from the resident.

Our hysterectomy dropped her blood pressure, meet me in her room!

The seen was serene.  Our patients blood pressure was low indeed, but she was none the worse for it.  Her belly was tender, but not alarmingly so given her recent surgery.  We checked the numbers again manually, adjusted the fluids, and sent stat labs.  We had no idea how long of a night we were in for.

As the hours passed the blood pressure continued to drop after each bolus of fluid.  Serial blood counts showed that the hemoglobin was dropping disturbingly.  I ordered a few units of packed red blood cells and listened to the resident arguing with the attending.

She's bleeding out.  We need to go back to the OR now!

The attending, however, was unconvinced.  In a strange haze of denial, she came up with any and every reason not to take the patient to the operating table. And so the resident and I sat at the bedside all night adjusting IV's, ordering more transfusions, and praying.

The miracle came around five o'clock the next morning.  The hypotension resolved.  The counts stabilized.  Large purplish bruises outlined the patients abdomen and back, a reminder of the huge amounts of blood that had been lost.  The resident and I figured that the fussy bleeder must have finally tamponaded.

The attending rounded in her usual fashion.  She entered the patients room with an air of confidence.  She turned to the resident smugly and barked off a few orders.  It was clear that she was patting herself on the back for what she believed had been the right decision. 

Years later, I still find it surprising that our patient survived the night.  I have no doubt that the right thing to do would have been to return to the OR immediately and address the hemorrhage surgically.

And this seems to be the problem with difficult, involved decisions.  Sometimes the decision makers are vested emotionally and otherwise. Often our vision is clouded, even when the correct path of action is undeniably staring us in the face.

As the drumbeat of healthcare reform marches on, there are those physicians and policymakers who call for greater regulation and more reporting.

Physicians like myself, working in the trenches, find ourselves backed into a familiar corner.

Our patient lies in the bed hemorrhaging, and we stand close by with both hands tied behind our backs hoping upon hope,

for another unlikely miracle.

Wednesday, July 17, 2013

Should Lawyers Be The New Doctors?

Dear patients,

It has been a hard week. I wanted to take a moment to personally apologize for all that you have endured. As one who has witnessed your pains and struggles, I can only wince with each new passing hurdle you are forced to leap over. This business of disease and illness is not for the weak of heart (metaphorically, that is).

To the man stranded in the hospital with a pelvic fracture, I wanted to say I'm sorry. Contrary to what you have been told, it was not I who gave the order to make your admission an observation. In fact, I did just the opposite. I had clicked the full admission order while doing the requisite computer work after seeing you that first night in the hospital. But the next day, I received a call from a physician in a distant city who has been paid by the medical center to review such cases. Although he reluctantly admitted that he is a pediatrician who doesn't even take care of adults, he has been given the power to interpret medicare rules and has decided that you don't qualify for inpatient status. Unfortunately it is of little interest to medicare, or this physician, that you are non ambulatory and that your wife is to frail to lift you. If you want to go to a skilled facility to strengthen before returning home, you'll have to pay for it yourself.

I'm sorry for the young woman I saw in the office crippled by pain caused by gastroesophageal reflux. I cannot explain why your insurance company has decided to deny my prescription for twice a day prilosec. I am aware that they have always filled it in the past. I am also aware that you have now been out of medication for a week, and are in severe discomfort. It baffles the human mind to understand the foibles of prescription coverage. It would be impossible for the insurance company to know, as I do, that you had been hospitalized with these symptoms and only by using the medicine twice a day have you found relief. This is a secret that only you and I share.

I'm sorry to the middle aged man who unexpectedly suffered a life altering stroke. Unable to walk, I had great hope that a motorized wheel chair would give you the mobility and Independence that had been cruelly taken from you. I filled out the paperwork as carefully as I knew how, but the request was denied. I know that the world is full of fraud and misuse, but surely even the most uneducated could see that you are a perfect candidate for such technology.

I guess I can only imagine the unendurable suffering to all of you caused by such indiscriminate shows of brute force by our medical system. I too suffer. Not, of course, like you. I ache from the depths of my being when the product of my life's work is sour and impotent. I spent all those years learning how to become a healer, a secretary and insurance negotiator I am not.

My skill set no longer matches your needs.

Perhaps a lawyer would get you farther.

Friday, July 12, 2013

Happy Birthday To Me

The guy hobbling into my office was literally a lifetime ahead of me. On the day of our visit, he was turning eighty and I forty. We shared a birthday. Things started as usual, an exchange of pleasantries and and then on to medical issues. What really concerned him that day, however, was his son. He still hadn't got married yet. Then there was his garden, his tomatoes were over watered.

We chatted easily as I finished my exam. His blood pressure was stable and his diabetes was controlled with diet only. I pushed my computer to the side and took a long look at him. He was exactly what most of us strived to be. Healthy and active,he was tackling his eighth decade with grace and beauty. I paused at my own reticence in leaving the thirties behind. It was a big day for both of us. Then I asked the question that had been on my mind about myself since waking up that morning (just change the number.)

So how does it feel to be eighty?

He smiled before answering. I sensed both pride and melancholy.

I still wake up every morning with the sweet taste of dreams on my tongue and a new plan for each day.

We both chuckled before I replied.

Ya, me too!

Monday, July 8, 2013

Are We Legislating A Primary Care Crisis?

It was the same years ago in residency. There was both a categorical and primary care residency track. Each had their own distinctive curriculum and rotation schedule. The outpatient track did more time in the clinic, the categorical more on the hospital wards. We trained side by side. We attended many of the same lectures. And our fellowship choices matched identically. In fact, most of my colleagues from the primary care group are now cardiologists, gastroenterologists, and pulmonologists. Even then, those in training changed their opinion midstream when they realized what their professional lives would entail.

It has become vogue to blame doctors and academic institutions for the falling number of generalists. We wag our fingers at the university behemoth who takes government moneys and then trains super specialized physicians. But, if you have been in education long enough, you know that the primary care push has been going on for decades. It just hasn't been that successful. Students and young physicians, time and again, change paths when faced with the day to day work of comprehensive primary care even though it is one of the most challenging and fulfilling jobs in medicine.

Indeed, one might say we have come here by our own careful planning. We have legislated it that way.

When you create a body that advises medicare on payment structure which is made largely of specialists and proceduralists and has no interest in protecting cognitive medicine,

You have legislated a primary care crisis.

When you create electronic medical records and define how to use them meaningfully, pushing physicians to waste their precious little time in the exam room on data entry,

You have legislated a primary care crisis.

When you pass a colossal healthcare reform package heavy on regulation and reporting, most of which falls on the lowly family physician toiling in the overcrowded office,

You have legislated a primary care crisis.

When you fight fraud and over billing of the few, by committing the many to ornate and easily deniable paperwork that everyone but the primary care doctor refuses to fill out,

You have legislated a primary care crisis.

When you tell hard working and well trained physicians that they can no longer go to the hospital, create inconceivable amounts of paperwork for those who do, and then try to replace them in their offices with nurse practitioners and physician assistants,

You have legislated a primary care crisis.

And lastly, when you tell them to abandon the doctor-patient dyad, and become team leaders in charge of administratively managing groups of non physician providers and turn them into community health gurus,

You have legislated a primary care crisis.

Saturday, July 6, 2013

Doctoring Requires A Loss Of Freedom

It hit me all the sudden.  The feeling of calm washed over my body as I relaxed my torso and let my legs stretch forward in the passenger's seat.  My wife was driving and the kids were in the back.  I had just signed out, and taken off my pager for the holiday weekend.  I knew the feeling was false.  The phone calls would eventually come whether I was covering or not.  And they did.  The nursing home was a responsibility that was mine only.


I can't imagine someone outside of medicine understanding this empirically.  The act of doctoring requires a certain loss of freedom.  When we open our doors to those who seek us, we close our lives to restfulness.  Gone are the lazy days in the backyard hammock without a care in the world. 

Yep, I said it.  Taking care of people is a burden.  A wonderful calling and a privilege, but a burden none the less.  And one of the consequences of taking on this great privilege is that you will never quite escape the covenant which you have signed up to fulfill. 

Weekends, holidays, vacations, they have all been interrupted by unexpected emergencies.  I accept this responsibility and have long ago forgotten how to lament the loss of placidity.

But sometimes, for a moment, I forget.  My mind a drift on the hope that comes with an uncommon day of rest in the middle of the week, I escape the beloved chains of the endeavor I have dedicated my life to.

It usually lasts for about a moment,

before my mobile rings and pulls me back to reality.