Sunday, February 26, 2017

Neither Was Mine

There are parts of medicine that are horrendous.  Moments too painful to recount.  Events that will break even the most innocent participants.

And then there is unspeakable magic.

I live for the days when a patient comes to the office with a particularly vexing set of symptoms.  Specialist after specialist bows their head in disagreement.  Laboratory values whisper falsehoods  with jeering tongues.  Symptoms are transient, physical exam signs inconsistent, and in the midst of head scratching an answer mysteriously appears.  Maybe a common presentation of a rare disease.  Or a rare presentation of a common disease.

Explaining with words so fast that sentences jumble.  Ideas merge.  The patient shakes their head enthusiastically less because of deep understanding, and more because they know that my excitement means that finally the answer will unfold like a blossoming flower selflessly bearing its pollen.  I will eventually slow down enough to present a cogent explanation.  And things will get better.

It lifts me up when a patient sits down beside me after yet another round of chemo.  When, at the end of the day, I have a sparing moment to settle in for intense conversation.   I bite my tongue, become quiet, and listen.  I hear of hopes and dreams.  I hear of pain and suffering, joy and fear. We talk like doctor and patient.  Like friends.  Family members.

We get past the intangibles of life and death, and move on to the more palpable like dignity.  Upon finishing, we leave the room in strength.  We leave the room with resolve.  We leave the room with tears in our eyes.  All of us.

And I love when an unwitting pattern is recalled from the deepest depths of memory.  The clock is ticking.  Heart beats rise and fall rapidly.  Knowledge accrued from past struggles presents itself at the most opportune time, and a life is saved.

On the triumphant drive home from the hospital, with the radio blaring, I remember the patient whose back such life saving knowledge was attained.

And I rejoice that all their suffering was not in vain, and neither was mine.

Wednesday, February 22, 2017

A Difficult Patient

I have come to believe that humility is an essential component of wisdom.  Never have I found this more true than in the practice of medicine.  In fact, for almost every atrocious professional error in judgment I have made, I can pinpoint the exact moment where I stopped being humble.

Yet time and time again, humility quickly disappears when dealing with the difficult patient.  In fact the label, difficult, assumes the problem lies within the patient and not the technique being utilized by the care provider. Already blame is turned outward and personal responsibility abandoned.

A few years ago, when I was in a group practice, one of the senior partners had a particularly needy patient that somehow showed up on all our schedules from time to time.  Her aged joints carried her into the exam room to their own particular hobbled rhythm.  She paused before each sentence, her voice barely above a whisper.

Her litany of issues was long and nonsensical.  And this was always the precise moment when humility left the room.  We all became convinced that her complaints were largely psychosomatic.  And we were right.  It still amazes me at how cavalier I can be when I think a solution is either simple or non physiologic.

It was only after several visits that the need for a thorough exam became apparent.  I tapped my feet and waited outside the door for what seemed like an eternity as she undressed and climbed into the unflattering gown.  My stethoscope stumbled over the heart as if its mighty muscle had not thumped hundreds of thousands of beats.  Auscultated the lungs absentmindedly untouched by the unmeasurable volumes that glanced the porous surface.

My hands fumbled over the fibrosed joints that absorbed the shock of a child's prance, a young athlete's stride, and an ancient shuffle.

My conceit, however, unshakable as it was, was shattered by the faded serial number tattooed on her forearm.

And my humility, once again, was restored to a respectable level.


Sunday, February 19, 2017

No Longer There

The phone is ringing.

The phone is ringing.


I sometimes feel my heart race.  In the middle of the night.  When I get a phone call. Or during the day.  While taking a leisurely walk with my family by the lake. The sun streaming through clouds on a brisk morning, interrupted by a fall in room 36.  An abrasion.  A cardiac arrest.   One phone call on top of another,  Occasionally so many that the calls on hold are dropped.  Or not so occasionally.

During dinner.  While in the shower.  Sitting on the toilet.  Day and night. A faint pain in the ear where the blue tooth rests.  Even when it is charging on the bedside table.  A hallucination.  The feeling of something that is no longer there.  Of something that is undeniably no longer there.

The vexing confusion on the other side of the line when I answer professionally, and the call is personal.  An even greater confusion when I answer personally, and the call is professional.  Straining to hear life altering results in a crowded restaurant.  Above the raucous sounds of my frolicking children.  In the car when the light is changing.  

A bad connection.  The basement where there is never reception. At the car wash when the blue tooth flips from my ear to the car, giving the employees an unexpected treat.  Or the waiter who stammers through my conversation concerning constipation, or blood in the stool, or foul smelling urine.  To return to ordering a hamburger, after telling a family member that their loved one has just died.

Upon realizing a few minutes after being woken unexpectedly in the middle of the night, that a pertinent detail was missed.  Waiting several minutes to get the nurse back onto the phone.  And languishing the next few hours restless. despite great fatigue, because now the mind has started spinning uncontrollably.

Distracted conversations with my wife.  Consistently interrupted.  By a patient's emergency.

The ire I feel receiving yet another text.  To only discover.  That it is just my precious daughter.

Telling me she loves me.

In the middle of a blog post...

Thursday, February 16, 2017

Five Moments-Coming Soon

Tuesday, February 14, 2017

I Don't Understand Burnout

I have a confession to make.  I don't understand the concept of burnout.  I mean, I get the idea.  Medicine is, at least when you are the kind of doctor who deals with life and death, inherently stressful.  And I feel the stress.  It's as if someone applied a vice grip to my insides in the middle of medical school, and it has never let up since.  The pressure is unrelenting, progressive, and downright painful.  It has gotten worse with every successive career milestone.

Brutal.  It's brutal.  I new it would be after a few weeks of rotations on the medical wards.  The more responsibility I gained, the worse it got.  And I guess I entered the profession knowing this.  There was no expectation of reprieve.  No belief that I would be let off the hook.  I assumed that it was my cross to bear, my burden to shoulder.  As the burden became heavier, I learned how to amble through hospital halls with a stooped posture.

I just don't know if it could be any other way.  I can think of no relief from the burden of making life and death decisions.  What we do.  What we do matters.  A wrong turn, a flip on the ideological scale, can have devastating consequences for those we care for.  There is no escaping this responsibility.  No blunting the effect.  You can't go half way. You can't stand in the middle of the road.  You either make definitive decisions with definitive consequences or you get out of the business.  There is no such thing as sleeping peacefully for a physician.

So why are doctors committing suicide? Why are doctors leaving medicine in droves?  It's not burnout.  A small part of the reason is wrong career choice.  A young doctor realizes quickly that they didn't know what they were signing up for.

For the rest, it's external.  It's not the stress of caring for people or even making life and death decisions.  This is part of our genetic makeup.  Part of our training.

It's everything else.  It's the paperwork.  It's the meaningless paperwork.  It's the droves of administrators and clerical staff thwarting us at every turn.  It's the government and endless regulations, and rules, and threats.  It's the loss of respect, loss of standing, and loss of confidence that we feel everyday from our community.  It's economic distress.

We won't fix this by training our young people about burnout or haranguing them with some odd belief in resilience.  They made it through medical school, they already are resilient.

You want doctors to be doctors again?  You want us to love our jobs again?

Simple.  Get out of the way.

And let us do what we were trained to do.

Friday, February 10, 2017


My son,

You will face this.  You will stand at the crossroads of skill and preparedness.  Although your heart may tremble, your hands will be still.  Although your thoughts may race, your mind will be firm.  Each one of us must enter the coliseum unadorned from time to time.  Over and over again, we do battle.  Skill and knowledge spring forth from failure, not success.

I can help prepare you for this moment.  I can congeal my accrued wisdom into consumable morsels for you to chew.  I can arm you with knowledge and skill.  But I cannot do battle for you.  Not this time.  I will bring you to the trough, but now you must drink.

Drink from the well of fear and incertaintude.   Imbibe from the ocean of insecurity.  Place your head forward and savor both the bitter and sweet,

For you will be tested.  Again and again.  There are times when you will be ready, and times when you will not.  But there is strength deep down inside of you.  A voice that will lead the way.  Listen to that voice.  Follow its dictates.  Let your mind and heart propel you together.

You must become the clearest when you are down.  It is when you are most beleaguered, that wisdom dribbles in.  Be open to it.  Watch for it in the deepest pits of despair.  It will be you ladder.  It will be you life raft.

And you will succeed.  Maybe not this time.  Maybe not the next.  But eventually.

So, my son, I want you to go to school today and rip that math test apart.  I'll be thinking of you.

Thanks dad, I will.  No biggie.  

I hope your day at work is okay too.  

Hope none of the sick people die!

Monday, February 6, 2017

How the patient ends up on the wrong end of the stick

It would never have gone down this way ten years ago when length of stay was all the buzz.  The Cat Scan would have been done in the emergency department, and the patient would either have been discharged or admitted for a a quick observation stay.  Bing, bang, boom. One, two three.

Instead, the CT was pushed until morning.  A resident saw the patient at midnight and then not a single practitioner note in the EMR for nearly eighteen hours.  The hospitalist eventually deferred on the scan and called for a consult, which was scheduled for the next day because of the late hour.

After a busy day of surgery, the specialist showed up at 8pm and OK'ed the patient for discharge without any further studies.  But it was almost midnight, better to wait till the next day.  The social worker, in meetings all morning, didn't get the paperwork out to the nursing home till mid afternoon.  The nursing home accepted the patient, but only if delayed once more night due to poor staffing.

In all, the patient endured four days in the hospital without a significant diagnostic nor therapeutic intervention. He did, however, sustain a third degree decuibitious ulcer which would take weeks of wound care to heal.

I'm not sure when exactly the length of stay vs hospital readmission switch flipped.  I have a sneaking suspicion that with all this talk of readmission rates, the focus and priority of the hospitals and their hospitalist programs have changed.  Once again we have traded one slave master for another with untold and often unstudied consequences.  Don't be too hasty to discharge, we are told, you wouldn't want the patient to bounce back.  

This dance we dance with Medicare is complicated,  The incentive game sounds straight forward, but often is not.  While the hospital or doctor may be the recipient of all the carrots, the patient often finds themselves on the wrong end of the stick.

These are grand experiments we are forcing on our patients.  Unproven and untested, we must be aware that in the name of quality, we may be undoing much good.

Saturday, February 4, 2017

Turned Away

Too many times I feel 
We are losing time once shared 
And only when you're in ecstasy 
You seem to really care

I recognize the song immediately.  Chuckii Booker.  Turned Away.  Not the regular version, but the extended.  As the words rush over me, caressing my nostalgia, a memory, a moment comes back.  

I was standing behind the counter at Homer's Ice Cream on a brilliant summer morning before the doors opened.  We were setting up.  One of the managers turned the volume up, and the radio blared through the speakers. The shades had been pulled back from the storefront windows, and light streamed through the door and onto the wooden tables in the adjacent dining area.  A veteran, the summer year before college, I had mastered almost every job in the restaurant.  Served ice cream.  Fry maker.  Head grill master during rush hour. I inspected almost every inch of the building.  Polished every spot.  Cleaned the bathrooms and emptied the dreaded metal containers found only in the girl's room.

My collared work shirt held the italics Homer's logo in red over the breast.  I rolled the sleeves up and squared them off above the biceps.  I like to envision my arms bulging with arteries popping at just the right places.  There was a pull-up bar in the storage room, and we often ran back if we saw a pretty girl approaching.  Quickly, we would squeeze out a few reps before returning to the front with sweat falling from our brow.   

There were all sorts of other hijinks.  I was seventeen and unsure of myself.  My heart had been broken already once or twice.  So I acted out.  Had shake eating contests when the manager was otherwise occupied.  Gave away free food to my friends, only to find that it was deducted from my paycheck weeks later.  I caroused with my fellow employees, many of them older than I, in search of alcohol and adventure.  We broke the law occasionally; got caught from time to time.  

It was all an act.  Artificial bombast to divert from insecurity.  At the time, the lyrics stung, but were an anthem played over a killer track.

Turned away.  Turned away.  Why did you have to turn away?  Turned away from love.

Like so many young people, I was convinced that I was unloveable.  I ached for a idealized connection.  A connection that both I and the objects of my affection were too immature to grasp.  Surrounded by a family that adored me, I moped at home day after day both dreading and hopeful for my upcoming departure to college.  

Those words, that tune, stuck with me.  Long after I had successful relationships and realized that I was worthy of love.  Even after I got married and had children.  

Those words still move me.  My body still sways back and forth and I feel both the pain and joy.  

And my children mope around the house much as I had.  Younger than I was at the time, but no less struggling to find their way through a confusing and cold world.  

I turn the radio up and let the words spray from the speakers and drip onto their growing bodies.  

We dance around the room with complete abandon,

and I momentarily believe that everything will be okay.  

Wednesday, February 1, 2017

Opt Out

If you are planning on complying with MACRA, make sure to allot the appropriate time and funding necessary to update/upgrade your practice.  Realize that the measures will be arbitrary, the data implementation arduous, and the moments for live patient care fleeting.  Expect that no matter how Herculean the task may be, the finish line will move often and unexpectedly.  Prepare to get discouraged when your software needs to be updated, maybe every year, at a cost. At least someone will be profiting from all this wheel spinning.

Check, double check, triple check the data.  There will be a host of governmental administrators waiting to disqualify your practice based on technicality.  Dot all the i's, cross all the t's.  Remember that somewhere out there is a person whose sole purpose is to find error in your work and punish you. Their bonus depends on it.

Above all, don't forget that it is your patients that are most important.  All these extra hours and dollars won't make a spit of difference in their well being.   So you may want to squirrel away more personal time to do what you used to do all day long, before you agreed to these fanciful rules and regulations

Best of luck,

If you are planning to join an ACO or Medical Home, consider hiring more staff to manage the extra burden.  What with the health coaches and life experts, it is guaranteed your payroll will swell.  When not conducting team huddles and combing the data for trendspotting, you, of course, will get back to the business of helping patients with those burdensome medical problems.  You might feel the urge to expand to cover increased costs, but in reality you will be pushed to have smaller panels and see people less often.  Why have a billable visit to a physician when the government can get off cheap by using a coach instead?  They should be able to handle heart failure, right?

The bonus payments will cover the shortfall.  At least fifty percent.  The first year.  Until the requirements get harder,

But it's all for the greater good.

So you'll work it out somehow.

If your goal is to sell your practice to a big medical group, congratulations.  Don't expect to receive more than pennies on the dollar.  The days of getting a fair market value are long gone.  There are federal regulations, you know? You wouldn't want to be accused of inducement.  I'm sure the transition will be flawless and your salary guaranteed.  For a time.

You might get to keep that favorite nurse or secretary.  Much everything else will change though.  Your medical record, your hours, your payer mix.  You will work more, for less pay, and lose much control over your day to day activities.  At some point you may realize that all that money you are making for the practice is now going to some administrator or another.  Definitely not to you.

At least someone else will have to worry about all those details you loathed so much.  You are paying them to.

If you are working towards completing your maintenance of certification activities for the ABIM...

Wait.  Wait.  Does this all sound fairly miserable to you?  It does to me.   So do something!

Opt Out.

I'm not talking about filling out a silly form and sending it to the government (although that sometimes works too).

Remove yourself from the abuse.  Extirpate your income from Medicare and insurance companies.  It's more possible than you think.  There are at least a hundred different ways to do this.

I'm doing five of them right now.

Are you going to role over and play dead?

Or are you going to do something?