Monday, February 23, 2015

The Wolves Are Licking Their Lips

There is much sacred in the hallowed halls of medicine. As any other secret society, this fraternal order of health care professionals has its own language, costumes, and humor. The pathway from pre-medical student, medical student, resident, and finally to attending is heavily marked with ritual and ever-expanding responsibilities. The world opens and unfolds before the eyes of the novice.
There is no more enduring symbol of membership in this group than the modern-day hospital. For those who don’t belong, only fear and wonder lie behind the sliding glass doors of the entry to the emergency room. For the initiated, however, a highly classified world expands and defines our existence.  
It was in the hospital where I diagnosed my first disease. I led my first team. I saved my first life.

Read the rest of my post at The Medical Bag.

Sunday, February 22, 2015

Burned Out

Walter was far older than his chronological age.  A mere thirteen years, he kept company with a much older crew.  Doctors, nurses, and CNA's were his constant companions.  The other kids on his floor were either too sick to interact, or came and left within a matter of days.  But not Walter.  His heart was too weak to allow his departure, but too strong to be first in line for a transplant.

So he passed his spare time with the staff.  He often duped me and the other medical students out of our pocket change with some confidence game or another.  He was like a younger sibling, or maybe the hospital mascot.  Everybody knew him, and everybody loved him.  Unlike friends and neighbors, however, we knew the most intimate details of his medical history.  We examined his body and ordered blood tests.  We were in charge of his well being.

Walter was the patient I spent the most time with during my medical school career.  He was a constant presence throughout my three months of pediatrics.  The last day of my rotation, the nursing staff got the unexpected call.  Walter was prepped and taken to the operating room.  A child had died tragically, and Walter was given a second chance at life.  Around midnight my team snuck into the ICU and peeled back the curtain.

Walter was alive and well.  A breathing tube snaked from his mouth and chest tubes hung from his bedside.  The grayish pallor of his face had been replaced by a pink glow.  I took one last look back and left the ICU.  And left my pediatrics rotation.

And stepped out of Walter's life forever.

Years later, I am struck by how many times I have repeated this cycle in my medical career.  Patients come and go.  Doctor is inserted at most intense moment.  The patient dies, or leaves the hospital, or exits the nursing home, or moves away.  We live a life of transience.

I used to think of this as intimacy.  As I get older, I question this belief more and more.  For true intimacy, confidence is earned, not given forthright. It is the product of shared struggle and trust.  And when someone you are intimate with dies or leaves your life, there is a period of mourning, a time for closure.

What physicians experience today is feigned intimacy.  We swoop into people's lives during their most intense moments and leave abruptly.

It's no wonder most of us walk the hospital floors with gaping holes in our sides that only we are unable to see.


Gasping for air amongst the charred remains.

Burned out.

(If you liked this post, please check out my newly released book: I Am Your Doctor And This Is My Humble Opinion).

Wednesday, February 18, 2015

What is it like to be your primary care physician? How do day-to-day pressures, concerns and unfolding developments impact the one who looks after your health and wellbeing? What does your doctor feel about the responsibilities and nagging questions that are an integral part of every waking hour? What is it like to know that each routine decision is potentially life-altering to your care? Who cares about your future medical care?  
Jordan Grumet's writing builds an insider's level of understanding. His unique delivery is simple and eloquently succinct. His potential audience is at a critical juncture in medical-political development, particularly in the United States, and his impactful prose is already vitally felt by a growing number of readers. The timing is optimal for Jordan's writing to be published as a widely accessible collection of stories and essays. 
Reverent dedication to quality diagnostic care permeates his writing and motivates Jordan to share from the head and heart. Each new essay challenges his readers to think and feel, taking on the varying perspectives of his challenging, endearing and beloved patients, and of family members of the ill or dying. Jordan's words deepen our understanding of the unwelcome, or sometimes welcome, arrival of Death.  
Jordan opines from experience, while he illustrates doctor-patient relations; doctor-colleague conduct and cooperation; and the impact that exponentially increasing forms, restrictions, technology and time commitment have on the delivery of quality care to patients. You and I and all of those in the medical system feel the impact of this government- and insurance-driven regulatory environment. More and more physicians are shutting down, opting out or simply struggling to juggle the burden of imposed digital and paper requirements, while their expertise is in medicine. Quality medical care, based on face-to-face doctor-patient relationship building, is lagging as a result. Jordan Grumet delivers this news powerfully and persuasively. His ability to do so is both timely and important.  
Married with two children, he sometimes includes family members in descriptions of his daily life and medical practice. In one essay, Jordan relates how his son's birth reawakens a depth of feeling that he previously guarded tightly as protection from the emotional impact of his work. In story after short story, Jordan reveals to us just how he is able to channel a full range of emotions, healthily and consciously, into his daily interactions.  
To whom does Jordan's writing appeal? Doctors, nurses and ancillary support workers all relate strongly to his descriptions of the front lines of medical care. Lay people who care about the future of their own medical needs, and all who've felt the benefits of kindly delivered care, resonate with his words. These various reading audiences either nod knowingly, based on their own similar experiences, or burst into tears as they "get it" that a physician is called to devote such an ample measure of body, heart and soul to their compassionate care.  

Humility. Naked self-assessment. Doubt. Surety. Wonder. Devotion. A peek inside.

Tuesday, February 17, 2015

The New HMO Fiasco

There is no more perverse, more derailed concept in today’s health care environment than fee-for-service. Even Wikipedia knows true evil when it encounters it. Let’s read their definition:

Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Similarly, when patients are shielded from paying (cost-sharing) by health insurance coverage, they are incentivized to welcome any medical service that might do some good. FFS is the dominant physician payment method in the United States,[1] it raises costs, discourages the efficiencies of integrated care, and a variety of reform efforts have been attempted, recommended, or initiated to reduce its influence (such as moving towards bundled payments and capitation). In capitation, physicians are discouraged from performing procedures, including necessary ones, because they are not paid anything extra for performing them.

And yet, year after year, American health care has managed to stay afloat with this supposedly deranged scheme. In fact, provider payments have continued to spiral lower even as the overall cost of caring for our nation has increased dramatically. By most estimates, physician services only account for 10%-15% of annual spending.

Read the rest of my post at The Medical Bag.

Monday, February 16, 2015

When In The Course

As high school teachers go, he was an anomaly.  A rare mix of humor and excitement, he was able to extract from his students the last ounce of concentration left at the end of a busy school day.  He taught my United States history class.  Long after I had collected acceptances from colleges my senior year, I sat engaged and learning a subject I frankly had little interest in.

He was constant energy.  He zoomed about the room, the tempo of his voice nearly as erratic as it's volume.  The attention demanded by his motion was only second to the content of his lecture. He made history both intoxicating and palpable.  A memorizer of theorems, a solver of equations, I struggled to imbibe the spray of knowledge shooting in my direction.

I never studied so hard, and yet looked forward to each and every lesson plan.

One afternoon he walked into the classroom and wordlessly turned on the overhead projector.  I read quickly through the large text on the screen:

When in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.--That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, --That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn, that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security.--Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

It was the first two paragraphs of the declaration of independence.  Our assignment was to memorize the words.  Then we would have five minutes to write the paragraphs by rote memory.  The groans and sputters from the students lasted nearly the whole class.

Each night I sat with paper and pencil.  The first few days were spent memorizing.  My surprise, however, was that speed was also an issue.  Not only did I have to know the material, I had to be able to spew it back on command.  Occasionally my hands would cramp, and I would have to stop for a few minutes and rest.

By the day of the quiz, I must have written those paragraphs hundreds of times.  I and my classmates  finished with just seconds left.  Our teacher dutifully walked up and down the aisles collecting the loose-leaf papers covered with mostly illegible sprawl.  And then he paraded up to the front of the classroom, and with great pomp and circumstance he threw them into the trash.

The collective gasp was interrupted by a particularly brave girl in the front row.  She wanted to know why it was so important to memorize the words when we could look them up.

The teacher smiled wryly and a sparkle flashed across his face:

One day there may no longer be paper, or computers.

We all sat dumbfounded wondering if our beloved teacher had finally fallen of his rocker.

But strangely enough, years later, I still have those words deeply ingrained in my memory.

When in the course of human events... 

Maybe he was trying to teach us that the tyranny of despotism was not something read on paper but carried in one's bosom.  Our forefathers didn't need to memorize words because the fight for freedom and equality was emblazoned on their backs from personal experience.  Generations later, prospering from the battles our ancestors won, my teacher wanted his students to hold these ideas (and words) as dear as those who originally wrote them.

This is our foundation.

I find so many parallels with what is happening in medical education today.  We love to dispense with the old ways in favor of all that is new and shiny.  We are starting to talk of discarding large chunks of medical education as irrelevant.  We have mostly abandoned physical exam skills due to the flexibility and ease of diagnostic testing.

And I see my old teachers standing in font of me as if they were addressing a high school US history class:

What if there were no CT scans?

Wednesday, February 11, 2015

Is Medicare Unnecessarily Complicated?

I had one crowning achievement during my college career. Freshman year, I took the most challenging course the university had to offer. I still wake up in the middle of the night in a cold sweat with differential equations flying through my brain. Advanced calculus not only had a difficult subject matter, it also had a professor known for challenging even his most avid students.
I remember tackling the material with a voracity that I had never displayed in my course work before. I ate, slept, and inhaled the complex mathematical formulas. I couldn’t believe my eyes when I got the final grade back. 
Over the years, I have used the same skills gleaned from this class to build a successful career: hard work, methodical attention to detail, and a fastidious sense of organization. For the most part, I have been able to thrive in most settings. There have been few hurdles that I have not been able to eventually leap over.
Little did I know, however, that I would face my greatest challenge this year as I formed my own medical practice. For the first time, I was solely responsible for all the administrative work and credentialing with Medicare.
And it’s been a comedy of errors....
Read The rest of this post at The Medical Bag.

Monday, February 9, 2015

Losses and Gains

Loss is something all humans face in their everyday lives.  As a physician, the effects are often magnified.  People die, they move away, they graduate from your services, or occasionally they pursue care elsewhere.  Parting can sometimes bring relief, and others a deep sense of failure.  But with Clara, I'm not sure we actually parted.  Mostly, I was left with confusion.

Clara came to me by way of the nursing home.  Her family had brought her to the hospital when she became too weak to rise out of the reclining chair in her living room.  The hospital stay was short.  Multiple diagnoses were made: dehydration, deconditioning, and a urinary tract infection.  Her  transfer to the the skilled nursing facility was meant to give a few weeks of therapy to gather strength.

I came to see her from time to time.  Clara liked the personal interaction of the therapy room, but her daughter was unhappy with the pace of improvement.  We had a family meeting and adjusted the treatment plan accordingly.  I explained that Clara was well into her nineties, and sometimes improvement was not as fast or complete as we wish.  Her daughter heard my words, but seemed reluctant to agree with such uncertainty.  She was sure her mother just needed more pushing.

One night, I got a call from the nurse on duty informing me that Clara had fallen,  I came early the next morning to evaluate.  The staff had reported no pain at the time, but when I entered her room I new immediately that the hip was broken.  Her lower extremity was deformed and rotated inward.  We called an ambulance, and she was taken to the hospital.

I visited Clara everyday.  I discussed with her surgeon and family the prognosis.  The operation was a success, although Clara developed an infection and had to stay a few days in the intensive care unit.  Eventually, I wrote the order to transfer her back to the nursing home.

The head of nursing called later that day to tell me that Clara had decided to switch physicians.  Since we had formed what I thought was a strong doctor-patient bond, I took the news poorly.  A few days later she wheeled into me while I was leaving another patient's room.  She apologized that her daughter had demanded that she change physicians, and hoped I would continue to stop by and see her socially.

Over the next few months I interacted with Clara more than ever.  She searched me out at the nursing home, and showed off her progress each time.  First she was able to stand.  Then walk.  Finally she was chasing me up the stairs.

And I marvel now at how once again I lost a patient,

and yet this time gained a friend.

Monday, February 2, 2015

Is Doctoring Easier For Men?

She was everything one could ask for in a medical resident. During the few weeks she had been shadowing in my office, I found her fund of knowledge to be exceptional. Her intuition was right more times than not. And she negotiated the fine line between detached clinician and caring advocate. My patients loved her.
Did I forget to mention that she was exceptionally attractive? I hope so. I really feel that such things have little relevance in medical training (or life in general). Sure, I could tell that she was careful about how she presented herself. She dressed over-conservatively in an attempt to deflect attention from her looks. I occasionally noticed a prolonged stare by a young patient or a twinkle in an elderly gentleman’s eye, but for the most part everything ran smoothly.

Read the rest of my post at The Medical Bag.

The Spoils Of War

There was once a kind and merciful General.  His joy of the study of war could only be matched by his love for the soldiers who trained dutifully beneath him.  Day in and day out, he could be seen in the barracks beside his men.  He was both dogged and forgiving, relentless but affable.  His mind was laser sharp, and his physical agility could match that of any of his much younger recruits.

He was a nationalist.  More willing to devote his life to the calling of country than to risk those of the young people who gathered around him.  So his attention to detail was incessant, his expectations for his pupils absolute.  His men both feared and adored him.  Their greatest dread was disappointing the man who placed so much energy into their training.

And this General gained the reputation of having the tightest, most well trained crew. Their physical abilities only outmatched by their mental toughness and strategic planning.  Other troops vied to join this proud gathering of young men.  Many found that they were not tough enough, their skills too weak.

Because of his great ability and courage, the General was often asked to lead his men into battle.  He studied each engagement with great concentration, and spent many a night locked away in his office trying to divine the infinite possibilities of war.  He did not take such responsibilities lightly, and felt the acute sting of placing his troops in harms way.

There was one painful truth to being the General.  While he studied maps and battle formations, it was his men who put their lives on the line.  He encouraged, threatened, and persuaded such young hearts to risk all for him.  For country.  

He had once done so.  He had watched his brothers fall in battle beside him, and yet carried on.  He had tasted both blood and sweat stream from his own brow.  He had seen many victories and quite a few losses over the years.  He survived long enough that eventually he was promoted out of the line of fire.  His knowledge and abilities were now thought too precious.

Year after year he toiled in the name of war.  Engagements were won and lost.  At the end of the day it was often hard to tell the difference. Each battle zone was littered with the bodies of men whom he loved dearly.

Some lives saved,

others mortally wounded by decisions that only he could have made.