Wednesday, October 30, 2013

Is The Doctor-Patient Relationship Like A Marriage?

It was like we were breaking up.

She stared at the ground longingly, and lifted her eyes from time to time as she spoke. She valued my care of her mother. She would never forget how I stood at the bedside during those last moments. And then there was her own health crisis. The emergency surgery was made more bearable by my familiar face in the emergency room explaining what would happen step by step.

She couldn't afford my new practice model. She crunched the numbers, and it just wasn't feasible. She didn't blame me. She understood that like any relationship, sometimes things just don't work out. Even businessmen and service providers have the right to raise their prices. She wouldn't argue with such innate American principles.

She was going to miss me, and I, her. The doctor-patient relationship can be like a marriage. Somewhere between the pointing and clicking, the arguing with insurance companies, and the struggles with preauthorizations, a true bond forms. We were two people, thrust together by unfortunate circumstances, who stood side by side for a portion of life's uncomfortable winding pathway.

Now our roads were diverging. For better or worse, we would go our separate ways. Many will look at me and point the finger of responsibility.

I will not deny my role in this unfortunate travesty.

But how many are facing similar circumstances forced by our current crumbling healthcare system? How many breakups are happening each day? How many primary care doctors are going concierge? How many internists are becoming hospitalists? How many pcps are being dropped from insurance panels as insurers respond to health care reform? How many physicians are refusing to take the new exchange coverage? And how many aging doctors are choosing retirement over meaningful use?

Marriages are being dissolved.

Relationships are being broken.

Who is paying the ultimate price?

Sunday, October 27, 2013

Somebody's Doctor

You won't at first.

I mean you will try.  But eventually the poor gentleman cowering in bed will just become the homeless guy in room 114.  New admissions will cease to be opportunities to heal or learn.  You will dread the extra work.  Blood on your hands will no longer be the ephemeral pulsating evidence of life recently passed, but instead will be the muck mixed with excrement that you mercilessly scrape from your soiled hands.

And in those lonesome times when you're well rested enough to surface from the meandering haze of responsibility and fear, you'll scoff at the refection in the mirror.  A mere shadow of your premedical self, you will feel nothing but disgust.

Who am I? What have I become?

Many will scold me for saying that it is inevitable.  Am I too callus?  The soft supple character that leads us to medicine becomes quickly incompatible with the harshness of having one's hands intertwined in the bowels of the dying.  We all are mangled by the inevitable gears that grind daily on the smooth surface of our psyches.

If you are lucky, you will hold on to your humanity when it is safe.  You will cry unnervingly at the end of a movie so much so that others will look on awkwardly.  You will seek pleasures, whether carnal or gastronomic.  You may decide to exercise more, run a marathon.

In those moments when the sweat drips from your brow and the muscles in your calfs strain, you will feel alive.  Maybe more than you ever did in the hospital.  This will calm the unnerving emptiness you sometimes feel at work.

Life will not always be so smooth.  Friends will tell you that you are distant.  Lovers will say that you can be cold.

But with time the joy you so carefully cultivate outside the examining room can inch it's way inward. You may not connect with every patient, but you will learn to hold a hand, touch a shoulder, shed a tear.  You will no longer be soft or naive, however, that is gone for good.

Maybe you will be wise. Kind. An old soul.

And life will pass before your eyes.

And one day, perhaps, you'll become a husband or wife.

A parent.

Somebody's doctor.

Thursday, October 24, 2013

Credit Due

I once mistakenly believed I knew nothing. Then after many years, with great hubris, I assumed a false sense of mastery over all that lay at my feet. It was only the wisdom of experience that taught me the truth lies somewhere in the vast in between.

It was nothing really, at least to me. I was in the midst of a busy, contentious, office meeting when my mobile began to buzz. I answered with the bitter taste of annoyance whipping from my tongue. It was a nurse from the skilled facility. My patient was declining. Frazzled by my surroundings and emotionally invested, I found just about every excuse for why she was wrong.

I looked at my watch impatiently as I calculated the time till finishing the meeting and the distance to the nursing home. It would be at least an hour. Mentally frozen by my preoccupation, the director of nursing jumped onto the line.

Dr. Grumet, we need to transfer him to the hospital.

A flash of anger rose red from my chest. Who was she anyway to question my judgement? Who does she think she is? But thankfully, the force of my own response made me pause. Indeed, she was the head nurse of the facility. Unlike me, she was currently staring at the patient as she had all day.

The fire in my belly cooled, the rage ebbed. I agreed to send the patient to the emergency room.

Hours later, I charted quietly at the nursing station. The director walked by and paused. I looked up and smiled humbly. I've learned over the years to give credit to people when they make good decisions.

You know you were right! Thanks for being forceful. I was too emotionally invested.

Her face lit up and she slipped away to her office.

I could tell that my admission had made an impact.

I guess doctors don't often give nurses credit when they are right.

And frankly, I think that's a shame.

Sunday, October 20, 2013

Cancer And Baseball

Drip. Drip. Drip.

I would eventually come to recognize the sound of lives sliding down the drain. The life of a physician would allow me a front row seat to the horrors of disease, premature death, and total financial destruction. But my earliest memories were of the small bathroom in the back of that little antiques store. The leaking faucet was just one of the many signs of the decrepit and decaying building.

Downtrodden as it was, the storefront housed a certain vitality that attracted young and sometimes lonely preteens like myself. The owner, on a fluke one morning, decided to sell his old collection of baseball cards beside his bevy of antique trinkets and refurbished armoires. His first customer, a know it all teen, quickly bought his best cards at a ridiculous discount. The owner, impressed by the young man's knowledge, quickly hired him.

The baseball business took over. Before he knew it, the owner was bringing in more on cards than antiques. The market was certainly there, kids came from all over the neighborhood. They congregated at the back of the store by the glass counter with eyes wide. They bought packs, opening them as fast as their little fingers would permit, and stuffed the free piece of gum into their mouths with one fell swoop.

But it wasn't just the cards, the kids were also drawn to the owner. He was both congenial and authoritative. A buddy when you needed one, he was also the perfect source of fatherly advice.

Still spinning from the death of my dad at such a young age, I found an oasis of comfort in the back of that little antiques store. It was located centrally between my school and the bus stop. Every day I would race out of class and blast through the door with my back pack in tow. During the summer, I spent countless days sorting through cards, hoping to hit the jackpot.

A group of us became friends in those safe confines. Many, like me, were awkward and struggling with social interaction. When the teenage employee went to college, the owner chose one of my friends to take his place. At first I was quite jealous. Years later, I realize that my friend was struggling in ways more profound than I. The owner was wise enough to extend the olive branch to someone who really needed a break.

Years passed. I transitioned to high school, changed districts, and my interest in baseball cards wained. I still stopped into the shop from time to time. The owner was struggling. He had been diagnosed with cancer and was undergoing treatment. Luckily, he would survive the cancer.

But his business wouldn't. He was just sick enough from chemo that he had to ask others to watch the shop for him. Without his electric personality, the baseball card business dried up. So did the antiques.

I came back from college one year to see that my beloved store had closed. A beading shop called Bedazzled took it's place. I heard that the owner had gone to work for one of the big card shops a few towns over.

And a small part of my childhood disappeared, like that. I would never find that place again.

I realize, however, that I was the lucky one. The owner, faced with the horror of cancer, survived only to find that the house he had so lovingly built had evaporated.

This kind, gentle, wonderful man.

I guess cancer doesn't take such things into account.

Monday, October 14, 2013

Who Is Responsible?

But doctor, ultimately it is your responsibility.

I can hear the case coordinator clicking her fingernails against the desk through the telephone line. I admit, I forgot to specify to the nurse, when she called me ten minutes before midnight, that this was a full admission and not an observation. In the absence of my order, a nurse manager reviewed the chart and decided that the ninety five year old woman with congestive heart failure and positive cardiac markers was appropriate for observation status. Of course the order can be changed, but one day will be lost. She will have to stay in the hospital an extra night in order to qualify for the nursing home.

But doctor, ultimately it is your responsibility.

The physician on the line doesn't actually practice medicine. He gets payed by the insurance company to sit behind a computer all day and talk to clinicians like me. I wonder if he knows what it feels like to push on a belly and suspect catastrophe. I do. And occasionally I order a stat cat scan on a patient who is writhing on my examining table to rule out such horrible things. Apparently I should have done a plain film first before moving to a cat scan. Maybe then the CT would be paid for?

But doctor, ultimately it is your responsibility.

The coding and compliance people are reviewing a dozen of my outpatient charts. Some are over coded, some under coded. Occasionally my ICD's are all wrong. It's funny how the quality of care means next to nothing. The dictates are quite clear. Follow these inane and often opaque rules, or get fined. Or god forbid even worse, you might just find yourself in jail!

It's no wonder, I slink out of the office most days with my head hanging low.

For me, medicine is oxygen. It is the bread that I nourish myself with, the draught that quenches my thirst. I have dedicated myself to no other master with such faithful resilience. I have stood on the mountain of knowledge and suffocated on the precipice of my own incompetence. Slept for minutes instead of hours. I battered and bruised my body in the most unhealthy ways. I have been cowed by the humility and shear fear it takes to be responsible for the lives of my patients.

But nothing, nothing is as utterly demoralizing as being told, day in and day out, how irresponsible I am.

Saturday, October 12, 2013

I Will Come To The Water

When I was young, I stumbled up the mountain in search of knowledge. Years later, I descended to the water when knowing no longer quenched my thirst.

I took the news poorly even though I barely knew the woman. We had talked on the phone a few times, over the years, regarding shared patients. I heard that she loved to swim.

They found her car parked in the lot adjacent to the beach. It was rumored that she was far too strong a swimmer for this to be an accident. But later there were whispers that she swallowed a bevy of pills before striding confidently into the waves that early morning. They fished her body out of the water hours later.

And I wondered about this lonely profession that we share. I have said multiple times that physicians are like islands floating in the vast sea. We may interact with others from time to time, but we are mostly on our own. There is no one with us in the middle of the night as we answer persistent phone calls. We carry the weight of the consequences of these decisions largely in solitary.

I heard that she was embroiled in a law suit, someone mentioned a federal investigation into illegally purchasing chemotherapeutic agents to offer to her patients at a discount. I highly doubt most of it.

I imagine that she was enamored with the water. We return our dead to the land for the most part, but maybe burial at sea is more appropriate. Our bodies are water after all. Her plasma mixing with the unimaginable vastness, maybe she no longer felt alone.

I kind of wish they had left her body where they found it.

As sad as I am by her passing, she made her own decision. I continue to mourn, however, for the rest of us. The pressure of practicing medicine is enough, dealing with the rules and regulations is becoming unbearable. And we are all still stuck in our sad, broken silos.

In a world of loneliness, we still haven't found a way to wither these tumultuous seas together.

I am sorry that I didn't get the chance to know her better,

I hope she found the peace that she was looking for.

Thursday, October 10, 2013

Have Physicians Lost Their Backbone?

What ever happened to courage?

Jim came through the choleycystectomy beautifully. In fact, he did so well that in no time he was back on the basketball court. Three weeks later he was in my office with a sore, swollen leg. He thought it was from twisting his ankle the day before. And indeed, it had all the appearances of a sports injury. I examined the extremity carefully, and decided to get a venous doppler to evaluate for DVT given the recent surgery.

My suspicions were confirmed when the technician called to tell me that he had found a clot in the deep veins of the thigh. Shortly after hanging up, my phone started to ring again. Jim was calling on his mobile. He was having chest pain when taking deep breaths, and his heart was racing. He was struggling to catch his breath. Certain that he was having a pulmonary embolism, I instructed him to walk down the stairs from the doppler suite to the emergency room.

I phoned ahead and talked to the ER doc on shift for the evening. I let him know of the positive study and my suspicion of a pulmonary embolism. We needed to start anticoagulation and admit overnight. He informed me that the ER was full, and likely it would be late evening before a bed was assigned.

I fell asleep early, awaiting the call from the floor nurse to give admitting orders. It never came.

I woke up the next morning disoriented and rushed to the hospital. Apparently Jim was accidentally admitted to the hospitalist on call. After reading the chart, I started to feel the blood rise to my forehead. The hospitalist ordered a cat scan of the chest as well as hypercoaguability studies. I was seething.

Why ever would he needlessly expose my patient to the radiation of a cat scan when the diagnosis of a pulmonary embolism was all but certain given the positive lower extremity doppler? And why would anyone order hypercoaguability studies when we had two perfectly good reasons for a clot to form: recent surgery and a sports related injury?

The cat scan showed a pulmonary embolism and the hypercoaguability studies were negative. Duh! I called the hospitalist to ask why he ordered such expensive and possibly dangerous studies on my patient when they weren't necessary. After much bickering back and forth, it became clear that although the diagnosis was certain, he didn't feel comfortable without having proof. The hypercoaguability studies were done "just to be extra careful".

I was pissed!

Now more then ever, in this time of economic upheaval and floundering medical quality, we physicians have to have the courage to practice responsible, parsimonious medicine. We can no longer offer costly or dangerous medical care just to "reassure" ourselves. We have to make the tough decisions.

We must have the courage to not treat minor bronchitis with antibiotics.

We must have the courage to not use narcotics for run of the mill back pain.

We must have the courage to use palliative care and hospice effectively when appropriate.

We spent years developing the knowledge and skill to efficiently and effectively treat our patients in a sound and thoughtful manner.

When will we develop the backbone?

Tuesday, October 8, 2013

Selfish Empathy

Forgive me.

I went to a funeral today. I listened intently as various friends and family of the deceased regaled in what is and what was. The rabbi at the lectern was somber. His voice floated through the room both melancholy and hopeful. As he cleared his throat to begin the Mourner's Kaddish, I was again dragged back to childhood.

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

This chant, this prayer, this island of familiar in a sea of horrific will always remind me of my dad. His death is my earliest remembrance of these foreign but comforting words. I listened as a child intently at his funeral. Then, year after year, in synagogue, my mom would bring us to remember on his yahrzeit.

And it is through these shattered lenses; through this prism that I experience grief.

When my patients die, when I hold their families hands, I am remembering. When I attend a funeral, or pat a shoulder gently and sigh, I am reliving. Not the beauty and wonder of the life before me, because I will never feel as profoundly as the poor husband, child, or sibling. But the epic loss that pervades my existence.

In your father, I see my father. In you, I see myself. Forgive me if my grief is divided.

I empathize with your pain.

And your grief brings me back,

to my own.

Saturday, October 5, 2013

Death And Privilege

When I say it's a privilege I see your eyes go cross. You think I'm daft. You reason that you are to young too talk about such things, or old but healthy, or that the cancer has spread but you want to remain optimistic. And I shake my head and think of my father.

He never had the luxury.

At the age of forty, he left early one morning to round at the hospital and never came back. A small blood vessel burst in his brain causing irreparable havoc. By the time we arrived, he was connected to all the appropriate machines. Back then, there was no talk of such things as preexisting wishes. The neurosurgeon, my father's colleague, told us he was gone and the ventilator was removed. His body quickly caught up with his severely damaged brain. He died.

You see, my father passed way before he was afforded the privilege we are discussing today; the privilege of seeing death as a shimmery mirage somewhere in the distant future.

The privilege of having a modicum of control over that which you fear the most is a gift. I humbly offer this to you.

Please take some time to think about your code status and advanced directives.

Thursday, October 3, 2013


(This would be the start of a great #hcsm joke)

@hjluks walks into the lobby of a posh New York athletic club. I am sitting by the elevators. While he approches, I marvel at how easily I recognize him. It's not that he looks so much like his twitter avatar, I just feel like I've met him before. We shake hands and embrace.

The conversation begins as if we we starting where we left off last time. But there was no last time. We exchange pleasantries and go right to substance. I look over at the elevator bank wondering if we should go up to the conference room, or just stand in the walkway. And talk forever.

Eventually we make our way to the tenth floor. Over bagels and fruit we welcome each participant as they arrive. Some of us have met before, others have not. Our content, however, belays a sense of commonality. We may be diverse in experience and profession, but we share certain ties.

The meeting has it's ebb and flow. I am beginning to form archetypes in my mind of the participants. To my right is @dlschermd. He lends me his marker from time to time (mine is barely functional).

@dlschermd reminds me of the brilliant professor that we all had in college, but better. He's neither bumbling nor arrogant. His generosity of thought far outweighs his freedom with writing utensils. Measured and insightful, the room becomes silent when he speaks.

Across from me sits @joshuaschwimmer. I can feels his gaze upon me when I speak. He is concentrating, dissecting. When he raises his voice to reply, I am completely sure that the first sentence will have the word "app" in it. And I'm right, but what comes next is often brilliant and throws my opinions completely on their side. Sometimes he says something and I think he is completely off base, till I realize that he is about ten steps ahead of me and I hadn't thought it out completely yet.

@PhilBaumann is calm and collected. He forgives me multiple times for interrupting without so much as making a grimace. He waits until there is a lull in the conversation and then proceeds forward. Although I have no basis for my opinion, I get the feeling that below the surface there is a ferocity. Controlled, tamed, but deadly when necessary. I wouldn't want to be on the wrong side of a heated argument with him.

Through @nickdawson (and @PhilBaumann)I can feel the patient advocacy shine through. @nickdawson is one of those rare people who speaks of ACOs and value based purchasing not with the grime of consumerism dripping from his lips, but with a zeal for providing more services for less cost for those in need. He later told me that as a hospital administrator he would sit in various places in his facility with a laptop and observe. I bet no one ever asked him to do this.

@hjluks sits towards the front. Calm. Engaged. He talks exactly the way he blogs. Disparate ideas become cohesive thoughts, wrapped in a bow and presented to us in such orderly fashion that one wonders if the problems of the world are really so unsolvable.

And all these fine gentleman tolerate my verbose and often repetitive opinions. They are confident in who they are.

The meeting ends and I lament that I have to say goodbye to Howard, David, Joshua, Phil, and Nick. It's been such a gratifying conversation.

I'm hoping I'll be lucky enough to get to drop the @ sign again soon.

Tuesday, October 1, 2013

There Is No I In Team

I was spiking a fever.

It was as if someone flipped a light switch inside my body. I could feel the sensation rise through the chest, and trample the dazed contents of my skull. Light, however, was a poor, lazy metaphor. There was no heat, only stimulation.

My belly ached from the repetitive heaving that preceded the fever. I envisioned the sandwich I had eaten that afternoon. I pictured small bacteria crowding into the generous dollop of mayonnaise wantonly placed by the store clerk. It was food poisoning. I was sure of it.

I cautiously sipped from the glass of water on the bedside table. My mouth, parched and yearning, was ignoring the revulsion in my mid section. I celebrated the brief ecstasy of quenching the abominable thirst before my belly began to swirl. I got up and ran to the bathroom.

Collapsing back in bed, I looked glassy eyed at my mobile phone which had just begun to ring. I mustered my strength, and picked it up.

Dr. G, It's Lisa at the nursing home, Mr. W's pain is out of control again. I tried the five of roxanol with little effect. His family is getting anxious!

I took a deep breath, and gave a few orders. I then fell back into bed. I had a long night ahead of me.

In fact, my sleepless night came at the end of a long weekend. Not being on call, my family and I treated ourselves to a few days in the city. We swam, we rode bikes, we deserted at Ghiradelli's. Carefree fun in the sun, right?

Well, not exactly. My hour long bike ride was interrupted by three phone calls. While swimming, I had to keep my mobile close in a dry and safe place. And even a hot fudge Sunday couldn't be eaten without some medical question or another needing to be answered. All of this, on my weekend off.

It has become popular to describe my breed of physician as outdated; to say that we have a hero complex, and can't adapt to today's team based mentality. If we would just loosen the reins and hand off some of the responsibility. Groups think better than individuals!

Unfortunately, I have found it all but impossible to "hand off" large numbers of debilitated nursing home patients. The care is too complex, too involved. On the aforementioned weekend, during my little vacation, I had a patient die (expected), and another develop multiple pulmonary emboli. Not to mention the diagnosis and treatment of a slew of new infections as well as a minor fracture.

All of this was managed in the nursing home, with close coordination between staff and families.

When physicians unfamiliar with these kind of patients try to cover, bad things happen. Hospice patients get sent to the emergency room. Demented people get inappropriately put on antibiotics for nonexistent urinary tract infections. The quality of care goes down.

So when I get sick, or take a weekend off, you better believe that I am going to answer that phone call. Because many of those patients are suffering far worse than I. It's not that I am trying to be a hero.

I'm hoping to become the kind of physician that I would want to care for my loved ones.