Monday, March 30, 2015

The ABIM Is Trying to Be relevant; Choose Wisely

The American Board of Internal Medicine is irrelevant.  It has always been.  I realized this when I first certified in Internal Medicine in 2002.  The test was largely fact based and filled with information that I would never need to know in practice.  It did not measure my diagnostic acumen, or my physical exam skills, or my ability to listen and empathize with my patients.

After passing the original test, I forgot mostly about it.  I filed my large diploma sized certificate in a drawer in the back of my office.  You see, I didn't display it prominently because I really didn't care if anyone saw it or not.  It meant nothing.  Not a single patient over ten years asked about my certification status.  It was irrelevant.

A decade into practice I recertified.  This time I was forced to do a number of maintenance of certification activities.  They were time consuming and expensive, but I figured it was the cost of doing business.  I didn't learn anything by participating in these activities.  They didn't help me take better care of my patients, and I didn't exit the process a more informed doctor. It was a waste of time and money.  Irrelevant.

Unfortunately, now the ABIM is trying to be relevant.  Not by creating a superior product or innovating in the continuing education space.  Instead it is foisting a new, sub par, labor-some, and most importantly costly product on its it's physician marketplace.  And it is doing it with the force of governmental mandate (ACA will require board certification as a quality indicator) and tacit support of hospital administrators everywhere (hospitals require board certification for hospital privileges).

This mostly annoying, but previously manageable requirement, has become a thorn in the side of American physicians.

The new MOC is just as irrelevant as the old, it's just a heck of a lot more difficult and expensive to complete.

I feel that it would be overly optimistic to expect the government or the hospital executives to release us from this arduous burden.  In fact, many of us suspect the government cheers on as physicians are forced to close doors and join the big academic or corporate sweat shops.  There is no political will to uncouple the ABIM from healthcare reform.

Hence, we physicians are left with two options.  We can either expose The ABIM as not only irrelevant but also crooked as Dr Wes Fisher has so excellently done.  Maybe this grand foolhardy organization will fall on it's own sword.

Or we can gather together and refuse to certify en mass, and see what happens to hospitals as they try to take away privileges from all their Internal Medicine doctors and specialists.

I think the time has come to make a decision.  Which will we choose?  We better choose wisely.

By the way, happy doctor's day!

Thursday, March 26, 2015

My First Dead Body

I assumed she asked because besides being a hospice volunteer,  I was a medical student and wouldn't get spooked by a dead body.  She probably didn't realize that it was my first week of classes and I hadn't experienced much yet.

She walked into the room with her head slightly bowed forward.  She was physically and emotionally exhausted.  Because of a scheduling snafu, there was only one nurse for the entire hospice floor.  This was her second patient to die that day.

She bayed me to come forward and help prepare the body.  I stared down at the lifeless figure.  I don't remember all the details, but I will never forget the stillness.   It was the first of many occasions where I would marvel at the appalling lack of motion that separates the living from the dead.

We were silent.  When she wanted me to perform some task or another she would point with her fingers.  I think we put an ID tag on the toes.  Maybe we cleaned the body and removed any remaining catheters.  The family had come and gone so there were no cosmetic issues of concern.

And then she took out the bag.  We gently rolled the body over and placed it cleanly underneath.  We pulled out the openings around the torso. Then we tucked in the limbs and head.  Finally she started at the toes and zipped up the bag from the bottom until she came to the face.

She stopped.

For me this was the shell of a man who I had never known.  But for her, for her, he was a breathing, feeling human being.  One whose hand she had held, whose family she had comforted, and whose excrement she had helped clean from his weakened and frail body.  She went to close the zipper but she couldn't.  I put one hand on her shoulder and reached over with the other removing her fingers.

She knelt down in the corner of the room and sobbed as I closed the bag.

Through years of medical education and practice there are many images burned into the depths of my soul.  But when I think of my first experience with a dead body, I don't see a body at all.

I see a nurse.

A humble, grieving, beautiful symbol of all that our profession can be.

Tuesday, March 24, 2015


I'd like to take a moment to update my readers on the progress of the last month since the publication of my book.

I have been selling copies over the web (click here) , and in person, and have been lucky enough to receive some press:

-Medpage today article: 10 Questions: Jordan Grumet

I will be appearing on a few Google Hangouts (Dates to be announced):

And I will be doing a book reading/storytelling on April 23rd at Bookends and Beginnings

If you haven't bought my book yet, check it out on my Amazon page and buy it!
If you have bought my book and liked it, please consider leaving an Amazon review, blog, or tweet a link to the book.

You can befriend my Facebook-Author Page here.
You can like my Book Page here.

Thank you again for all your help and support!

More blog posts to come.

Monday, March 23, 2015

My First Lesson In Humility

I remember being more confident that most of my peers.  The look of dread on my fellow interns face pre-call, and the fatigue post-call always seemed unnatural to me.  Maybe it was on account of my life-long pursuit of medicine.  I felt nothing but elation at the newly branded "M" and "D" that came after my name on the hospital badge.  I was no longer a volunteer, no longer a student.  I was a doctor.  And part of that persona was walking into the unknown with a certain amount of confidence.  This was exactly where I was meant to be.

A few months into internship, I admitted an obese lady with a skin infection on her thigh.  I started the appropriate antibiotics and waited.  My resident noting the appearance of the skin asked me to order an X-ray.  I placed the order but secretly was befuddled.  Why order an X-ray?  What on earth was that going to show?

I was on call and busied myself with the drudgery of being the low man on the totem pole.  I admitted  5 new patients.  I drew blood.  I did paperwork.  I spent hours in front of the computer screen looking up labs and filling out charts.  I forgot one thing though.

Maybe it was because I didn't understand my resident's clinical reasoning.  Maybe somewhere in the recesses of my mind I had written the order off as something superfluous or unnecessary.  To this day, I can't explain why I failed to follow up on the X-ray of the thigh and retrieve the results.  Some things may remain unexplained.

The next morning my resident and I breathlessly ran to the patient's room at her nurses prompting.  Her blood pressure was dangerously low and her temperature was sky high.  My resident looked at me in a panic and inquired about the X-ray.  After we stabilized the patient, we ran down the stairs to radiology and glanced at the films.  Our worst fears were confirmed upon staring up at the light box: subcutaneous gas.

The patient had necrotizing fasciitis ( a severe form of skin infection) and needed immediate surgery to remove as much of the infected tissue as possible.  She would likely lose her limb and possibly more.

Years later, I can't help but wonder how much better she would have done if I had seen the film the night before, and surgery had been called immediately.  The patient survived either way, but by a hair.

And I learned an important lesson that night in humility.  A lesson I would be taught over and over again as I journeyed through medical education and beyond.

Disease is tougher, more resilient, and far more cunning than the minds of the medical experts who struggle to tame it.

It is only to be rivaled by the human spirit of our brave patients, who battle day in and day out to survive.

Thursday, March 19, 2015

Time To Check Out

It was time to check out.

The trip had been a blast.  There was sun, and water, and too much food.  Of course there were moments of displeasure.  The rain came and went.  The skin turned red and hot, and I slathered sunscreen on almost every hour.  But all in all, I had few complaints.

Of course I wanted to stay longer.  Who wouldn't? There was so much to stay for.  If I was having fun now, who is to say that it wouldn't continue?  I had my family, beautiful scenery, all my electronics, and the ocean.

There was that prickly situation, however, of the contract.  I had only signed on for a certain amount of time.  And there was the money issue.  I had run through all I had been allotted.  My funds were low.  There was only so much my wallet could take.  I had searched every corner, shaken out it's contents including the lint.

Maybe I could stay anyway; lock the door to my room and refuse to leave.  They would come knocking, but I wouldn't answer.  I could cling to the bed, my lifeline.  My clothes would turn dirty and tattered.  My abdomen would became frail and gaunt because I surely would run through whatever tidbits were stuffed away in the little cooler in the corner.

Weak and debilitated, I probably wouldn't be able to enjoy my family the way I had before.  They would come to my bedside every day and hold vigil.  Their eyes drawn and their lives on hold, they would wait for me.

My body would start to itch from the irritation of the bed sheets causing endless discomfort.  The joints would stiffen and the spine would curve unnaturally.  And the beloved sun would be hidden behind the closed shades of my room.  The ocean would be a far off dream, a mirage hidden behind jaundiced eyes.

And I would suffer in this place that I once called paradise.  Suffer as my soul rebelled against such unnatural settings.  My mind might remain clear enough to change and give up this battle, but the muscles of my face may become too weak to verbalize my surrender.    

Nope.  That's not for me.

It had been such a wild, amazing trip.

But it was time to check out.

Monday, March 16, 2015

The Intimacy Gap

I used to think that there was a communication gulf between doctors and patients.  Somewhere in the hub-bub of of the harried office visit some secret sauce was missing.  A divide that was so fundamental that both parties often left the room feeling disjointed and uneasy.  Patients wondered if doctors truly heard them.  Physicians wondered if any one was listening to what they were saying.  The tension ebbed and flowed but never disappeared.  This has been the state of health care over the last decade.  This has been the environment in which I have built my clinical career.

I now believe that the term "communication" is imperfect and lacks the specificity that I am looking for.  I think what we truly have is an intimacy gap.  What separates doctors and patients is a disjointed and unnatural version of intimacy that in no way mirrors the important bonds that we form in real life non-medical relationships.

Let me explain.

A patient walks into the exam room and unloads the most intimate, embarrassing, and frightening secrets to their doctor.  Unlike close friends or loved ones, the physician has in no way earned this privilege.  They had not gained this right through hours of conversation, years of support, or acts of selflessness.  There is no shared struggle or trust.  It is given too freely.

The doctor listens patiently and kindheartedly.  But the interaction can only be so rewarding.  There is no mutual disclosure of secrets.  No bidirectional sharing of intimacy.  The physician remains stone faced, objectively detached.  This is what we learned in training.

The practitioner, conversely, is bombarded day in and day out with urgent and emergent situations.  There often is no normal period to engage and form stronger bonds.  They are shuttled from exam room to exam room trying to put out fires without any of the nicety of experiencing their patients during non turbulent times.

When disaster hits, physicians become immersed in someone else's pain and tragedy.  But when they die, or get better, or move away, we are plucked out of their lives and rarely are present for any sense of closure.  By then we have moved on to the next case, the next emergency.

Disjointed, unnatural intimacy.

I don't know how to solve this problem.

For my part, I have decided the only solution is to strive for mutual disclosure.  Maybe we, as physicians, can tell our stories.

We can tell our stories to those we care for,

so that they may also care for us.

My Book: I Am Your Doctor And This Is My Humble Opinion


Tuesday, March 10, 2015

Behind Every Doctor Is A Patient

Behind every doctor is a little boy or girl who once watched helplessly. Maybe it was her father or grandfather who suffered under the weight of a disease that was deemed all but incurable. Perhaps her own skin was battered and bruised by the repeated trauma of an unrelenting tourniquet.  She swore that when (if) she got older she would protect the innocent from such things.  Her vow was the light that guided her through arduous years of study and apprenticeship.  Her promise was etched into the depths of her psyche like those two dangling letters she worked so hard to get placed uncomfortably after her name on her hospital ID.

Behind every doctor is a medical student or resident.  A young man at first, his innocence was the first casualty of a mostly unexpected war.  At some point that boy saw something, felt something, that was far beyond his repertoire.  The shattered remnants were collected and placed back together into a facsimile of what had been before.  But the sum of the parts never quite amounted to the whole.  Those who looked closely enough could see how porous his nature had become.

Behind every doctor is just a person.  Haunted by the weight of her decisions. Baffled by the foibles of our legal system.  And asked to trade in his most sacred skills for a degree in data entry.  She is tired at the end of the day because she was on call the night before.  He is a husband, father, or son and languishes under the weight of such responsibilities as would be expected.

Behind every doctor is a patient.  Who suffers from time to time just as you do.  Who has good and bad days similar to yours.   Who may be a son of a bitch one visit, and a prince the next.  Don't let the artificial barriers of rank and title confuse you.  Don't let the complicated jargon and technological blockade distract you.

There is so much more in common than could ever pull us apart.

The only difference is that we have always had the privilege of hearing your most pressing stories.

Maybe it's time for you to hear ours.

I'll start by telling you mine.

I Am Your Doctor And This Is My Humble Opinion.

Sunday, March 8, 2015

What's Happening To Health Care, A Damn Shame?

I understand that there is a difference between perception and reality.  I also get that the kind of people one meets on a tropical vacation in the middle of March are of a certain economic and sociopolitical status.

Nonetheless, I am amazed at how history seems to repeat itself.  Year after year, while sitting in the shade and relaxing by the pool, I strike up a conversation with the vacationers sitting on either side of me.  The conversation starts innocently enough.  We talk of the details of our trips and about the kids.  More times than not, they are from Canada.  We bristle at the cold we left behind, and lament that these trips can only last so long.

Maybe we talk of politics or economics.  Eventually, however, they ask what I do for a living.  After a knowing glance, the litany of questions begins.  They inquire about my speciality, and other assorted details of my day to day life.  We chat for awhile before I get embarrassed at all the attention, and try to steer the conversation in a different direction.

But here's the kicker.  Just when I am about to successfully move to another subject, they go out of their way to stop me and say how great the American medical system is.  They declare Canadian health care to be horrible.  They deplore the hospitals.  They claim that getting into the doctors office takes months for routine visits, and weeks for emergencies.

And they all have these stories.  I can't tell you how many harrowing recollections I have heard of racing some child, parent, or loved one over the border to the US when they couldn't receive adequate care at home.  Upon crossing country lines, they checked into the nearest hospital mecca, and were lavished with top ranked medical care that literally solved all their problems.

I was as incredulous as you the first time I heard this kind of story.  By now, three or four times later, I can almost say the words before they are uttered out of my new friend's mouth.   Is there some hyperbole?  Probably.

The fact remains, though, that a healthy part of the population is unhappy with the care they are receiving.  In fact, many of them are paying extra concierge like fees for services that are expected as bare minimum in the United States.

When I tell these Canadians that the political winds are changing and that the goal is for our system to eventually be a lot more like theirs, they shake their heads.

It's a shame they say.

A damn shame.  

Now available on Amazon, I Am Your Doctor And This Is My Humble Opinion.

Tuesday, March 3, 2015

Does Medicare Allow For Agility and Innovation?

The call came around 10 pm on Saturday night. Helen was concerned by her mother’s cough and lethargy. I checked my schedule, and we agreed to meet at the house first thing in the morning. 
I awoke before the sun rose. My car rustled through the half-melted snow as I sped down the freeway. Thirty minutes later, I pulled up to the small bungalow at the end of the street. Helen and her husband greeted me at the door. The look of concern was apparent on both their faces.
We chatted for a few minutes before I went to the bedroom to do my exam. Helen felt her mother was generally doing well at home by herself, but the last few days had been rough. She caught a cough from one of the grandchildren and was slow to recover.  
I knelt at the bedside and examined my patient. She was alert and coherent.  There was a deep rattling sound coming from her left lower lung. Her mucous membranes were moist, but she was weak and resistant to getting out of bed. 
She had pneumonia.

See the rest of my post at The Medical Bag.

Sunday, March 1, 2015

The Wise Man, His Son, and the Camel

There is an ancient parable about a wise man who travels with is son and a camel through the desert on a long journey.  Being wise and kind, he estimates the sweltering heat will take a toll on his steadfast animal and so decides to unburden the beast for a short period.

My daughter is screaming.  She has planted herself on the ground in the middle of a shopping center, and dug her heals in.  She will not move.  After a day of disappointments she has reached her breaking point.  Overwhelmed by the helplessness of being a seven year old, she has decided to take control over the only thing she has left: her body.

My wife and I approach the situation cautiously.  Although our blood is starting to boil, we recognize a pattern of behavior that signals fatigue and probably hunger.  Our compassion is blunted by a repeated pattern that both of us know needs to be broken.  Even if her behavior has an explanation, at some point maladaptive actions need to be redirected into more mature coping skills.

People are starting to stare.

As with any journey of consequence, the wise man and his son encounter fellow travelers from time to time.   The first is a set of merchants, leading a caravan of pack animals lugging their wears from one port of commerce to the next.  They are men of few words but distinct opinions.  They shake their heads at the site of the two humans walking side by side with the camel unhindered by cargo.

"Such a hot day and these fools choose to walk instead of mount their animal"

We sit quietly next to our daughter and whisper calmly into her ears.  Our assuaging words are not having the desired effect.  She disagrees vociferously.  An older couple walking past looks down at us with disgust.  They don't speak, but their eyes say volumes.  They think it is unconscionable that we let our daughter treat us in this way.  In their day, a child only spoke when spoken to.  Adults these days have become so indulgent and have lost control.

My wife and I are all too aware of their opinions.  We feel the disapproval pitter-patter onto our backs like the first drops of what will become a torrential rain.  We try to tune the world out and redirect our attention to our daughter.

The wise man feeling the sting of disapproval  turns to his son and offers him a boost up onto the camel.  His son, already tired from the arduous journey, takes the reigns happily. 

Until they come upon a traveling gaggle of performers.  They are making the journey from one kingdom to the next to perform for some important prince or another.  They are clowns and acrobats, actors and comedians.  

Upon noticing the wise man accompanying his son perched atop the camel they shake their heads disapprovingly.  

"What of respect for one's elders?  The old man wears out his tired legs as his majesty, the spoiled child rides in luxury."

My anger is staring to grow.  We decide to change approaches.  We demand that my daughter get up immediately using our most stern and forceful voices.  She looks up at us and her crying gets even louder. She now is completely unhinged.

A small crowd has started to gather adjacent to one of the store fronts.  We can hear their whispers.  A  growing chorus of voices using distinct words but in hushed tones.  They feel bad for the poor child who is being harangued by her parents.  She needs patience and understanding, not anger.

Again embarrassed by the attention, the wise man switches places with his son and continues the monotonous expedition.  It is many more days before they encounter a group of smugglers brandishing weapons and overfilled casks of wine.

The smugglers appraise the wise man and his son and quickly realize that there is little to plunder or pillage.  They laugh as they pass at the ancient one.  Frail and old, he must rely on his poor son to lead him around on a camel.  

"Old man, old man, one step from the grave, use those wobbly knees while you still can!" they croon as they race by on their trusted steeds.

My wife finally gives up on negotiations and picks up my screaming daughter, and we walk quickly towards the exit.  Young and old see my daughters tears and make sweet comforting faces and wave in her direction.

The wise man jumps off the camel.  He stands beneath the animal, and with a great groan heaves it onto his shoulders.  And they finish their journey in this manner.  

They still encounter other people on the road, from time to time, who have a plethora of opinions.  

But now the passersby are too stunned to open their mouths.