That's it. I'm taking a tip from the hospitalist movement. I'm rebranding. I'm no longer a primary care physician. "PCP" now seems to be synonymous with overworked, underpaid "loser" who at least by some people's opinions aren't carrying their weight. That's not me.
So starting today I will be known as a "PREHOSPITALIST". That my ticket. I see patient's before they get to the hospital and try to divert them before they get sick enough to be admitted. I see the sickest of the sick. End stage renal disease, transplant patients, double transplant patients, end stage copd, end stage chf, end stage anything, and frequent fliers.
Send them all to me. Send me your hardest patients. And I will bend over backward to keep them out of the hospital. I will see them weekly. Daily if I have to. I'll manage them aggressively. I'll return their phone calls promptly. I'll fit them into my schedule at a moments notice.
And I will manage them. Comanage them with their specialists. In fact I will call the specialists so often to discuss management that they will be sick of me. But I will cut their hospitalization rate down by 75 percent. And they will get better. And utilize less resources, and thrive.
Yet I will still see healthy people. And do annual screenings. And make unexpected diagnosis. And while I may not be an expert in any field I will still know enough about most fileds. And when death comes I will be there to comfort. And to advise. A jack of all trades.
And I will be what used to be known as an internist. Or a pcp. Back in the days when those titles garnered respect. But don't you dare call me that now! I am a "prehospitalist" to you bucko. And don't you forget it!
Saturday, November 29, 2008
Wednesday, November 26, 2008
Monday, November 24, 2008
My Weekend
It was another weekend on call. Filled with the usual phone calls, hospital work, and Saturday clinic. I dread weekend's on call. Mostly because they take me away from my family. There is also, ofcourse, the lack of sleep. Getting up at 5am on Saturday is no fun. But this is what I do. Every third week. It is what it is.
My call, at least, this time was brightened by the morning clinic. I was a little bit less busy then usual so had more time to talk with my patients. A rare luxury, I like to take advantage of extra time when I get it. My first two patients were a man and a wife in their eighties who live in a local nursing home. After going into the regular littany of medical questions I started my exam. While taking blood pressure, stethoscoping, pushing and pulling.... curiosity got the best of me. I started in with the personal questions.
"So how long have youy been married?....How many kids to do you have? Grandkids? Great Grandkids? where did you both grow up?". I am always amazed at how much I learn from people by asking these type of questions. And as usual this couple surprised me.
I would have never guessed it from looking at them...but they had been only married for fifteen years! Apparently they had met in their teens and at the tender age of twenty she had refused his marriage proposal. Years passsed. They both married other people and had kids, they both got divorced. And forty years later after minimal contact he picked up the phone and called her and they realized that they lived blocks away. The rest was history.
A little later in the day I saw another patient who was relatively new to me. I had seen her only a few times for minor problems. Each time she came in accompanied by her daughter. And each time I kept thinking that I somehow had met her daughter before. But I just couldn't place her. As my patient was preparing to leave her daughter mentioned that, "oh by the way mom will be on TV next week!" And that's when it dawned on me. Her daughter looked familiar becuase I had seen her before...many times in fact, she is on a TV show I occasionally watch. How funny! I didn't even recognize her.
I guess it just goes to show that even a monotonous, boring, weekend on call can turn out to have some surprises.
My call, at least, this time was brightened by the morning clinic. I was a little bit less busy then usual so had more time to talk with my patients. A rare luxury, I like to take advantage of extra time when I get it. My first two patients were a man and a wife in their eighties who live in a local nursing home. After going into the regular littany of medical questions I started my exam. While taking blood pressure, stethoscoping, pushing and pulling.... curiosity got the best of me. I started in with the personal questions.
"So how long have youy been married?....How many kids to do you have? Grandkids? Great Grandkids? where did you both grow up?". I am always amazed at how much I learn from people by asking these type of questions. And as usual this couple surprised me.
I would have never guessed it from looking at them...but they had been only married for fifteen years! Apparently they had met in their teens and at the tender age of twenty she had refused his marriage proposal. Years passsed. They both married other people and had kids, they both got divorced. And forty years later after minimal contact he picked up the phone and called her and they realized that they lived blocks away. The rest was history.
A little later in the day I saw another patient who was relatively new to me. I had seen her only a few times for minor problems. Each time she came in accompanied by her daughter. And each time I kept thinking that I somehow had met her daughter before. But I just couldn't place her. As my patient was preparing to leave her daughter mentioned that, "oh by the way mom will be on TV next week!" And that's when it dawned on me. Her daughter looked familiar becuase I had seen her before...many times in fact, she is on a TV show I occasionally watch. How funny! I didn't even recognize her.
I guess it just goes to show that even a monotonous, boring, weekend on call can turn out to have some surprises.
Friday, November 21, 2008
Smile
It all starts with a sparkle.
As if the devil himself had placed just enough mischieviousness in your eyes to be bitter sweet. The sparkle evolves into a comet of bright white light sweetening your beautiful brown skin soft and smooth. Your lips part. The lower hiding your teeth while the other curls upward. Your face and body radiate, brightening the room and releasing all unwanted thoughts that dwell in my mind. And those word return. Filling my soul. Over and over again....
I love your smile
As if the devil himself had placed just enough mischieviousness in your eyes to be bitter sweet. The sparkle evolves into a comet of bright white light sweetening your beautiful brown skin soft and smooth. Your lips part. The lower hiding your teeth while the other curls upward. Your face and body radiate, brightening the room and releasing all unwanted thoughts that dwell in my mind. And those word return. Filling my soul. Over and over again....
I love your smile
Tuesday, November 18, 2008
Primary....Care
Early morning
The exam room.....
When I look in the mirror
A stranger stares back at me
How so?
The face is not mine
The eyes are too far apart
The left higher then the right
and the lips are too close to the nose
Could it be that you no longer recognize yourself?
And when I walk
Everything is leaning...
roads, sidewalks, people
Has your life lost balance?
And my chest
Every time I think
or worry
Pain
Is it your heart that hurts? Has the sadness consumed you?
And sometimes
sometimes
when I'm alone
I talk to myself
Like you have not a friend in the world?
Silence
And then a knock on the door
"Doctor....doctor?"
"Yes?" I respond awaking from my reverie
"Your first patient is here....
shall I send her in?"
From the chapbook Primary Care, The Lives You Touch Publications
The exam room.....
When I look in the mirror
A stranger stares back at me
How so?
The face is not mine
The eyes are too far apart
The left higher then the right
and the lips are too close to the nose
Could it be that you no longer recognize yourself?
And when I walk
Everything is leaning...
roads, sidewalks, people
Has your life lost balance?
And my chest
Every time I think
or worry
Pain
Is it your heart that hurts? Has the sadness consumed you?
And sometimes
sometimes
when I'm alone
I talk to myself
Like you have not a friend in the world?
Silence
And then a knock on the door
"Doctor....doctor?"
"Yes?" I respond awaking from my reverie
"Your first patient is here....
shall I send her in?"
From the chapbook Primary Care, The Lives You Touch Publications
Hospitals
Here's something you won't here your physician say everyday.....I hate hospitals!. I hate emergency rooms! I hate when my patients are sick enough to need emergency care. I hate when they get admitted.
Why...because hospitals are dangerous places where bad things can potentially happen and bad bugs hang out. It's a place for sick people...really sick people...deathly ill people. And I don't want to ever let my pateints get that way.
As I am fond of saying in my office...If you find yourself in a hospital you better be one of a few things....either really ill, visiting a friend, or at work. Because it's not the place for the kinda ill or sorta ill. Only bad things can happen to these people.
So if you call me in the middle of the night and expect that I'll tell you to go the the emergency room for your cold...you got another thing coming. Or if your an emergency room doctor and you want to admit my 50 year old patient with bronchitis....I'll probably give you a hard time.
It is my responsibility to protect my patients from the harms that they don't recognize. And let me repeat this to make it clear....the hospital is a great place if your on the cusp of dying.....but incredibly risky for everybody else.
Why...because hospitals are dangerous places where bad things can potentially happen and bad bugs hang out. It's a place for sick people...really sick people...deathly ill people. And I don't want to ever let my pateints get that way.
As I am fond of saying in my office...If you find yourself in a hospital you better be one of a few things....either really ill, visiting a friend, or at work. Because it's not the place for the kinda ill or sorta ill. Only bad things can happen to these people.
So if you call me in the middle of the night and expect that I'll tell you to go the the emergency room for your cold...you got another thing coming. Or if your an emergency room doctor and you want to admit my 50 year old patient with bronchitis....I'll probably give you a hard time.
It is my responsibility to protect my patients from the harms that they don't recognize. And let me repeat this to make it clear....the hospital is a great place if your on the cusp of dying.....but incredibly risky for everybody else.
Monday, November 17, 2008
My First Medical Blog Post (classic post)
This is a little bit long...but this is what started my medical blogging (around 2005?):
We tell ourselves the stories about our lives that make it bearable….our better yet magical, mystical.
When my father died unexpectedly, when I was seven, I had no words or stories that made sense. How could I explain how this loving father of three and devoted husband could be taken from this earth so quickly and with so little warning. It was a question that puzzled me throughout childhood.
As I grew older I unconsciously formulated the answer to this question. You see…my father died when I was seven years old. At this age, he was my idol. I wanted to be just like him. I copied his movements, his words, and of course I wanted to be a doctor too. My father was a highly respected oncologist and often treated the sickest people. He had received many accolades as well as the love and respect of his patients.
I figure, if he had lived longer, I may have outgrown this period. Maybe I would have reached an age where we fought more or I might have become disillusioned with him. Maybe I would have changed my mind and wanted to be a sports star or a policeman. Who knows? The point is this idea of being a doctor stuck with me. And it carried me.
It carried me through a learning disability; it carried me through a move. It carried me through successes and failures. It created a confidence that never questioned if…only questioned when.
That story made sense. My father’s death, tragic as it was, made concrete in me the idea of becoming a physician. And by doing this I would carry on the tradition and touch countless lives. From his death would come rebirth and renewal. I would help people….I would save lives. I would turn my sadness into good and beauty.
It almost pains me to read this last line. If I had known then how far this was from the truth………………………………
2
When I started residency training in July of 1999 I felt relatively confident. After all, this is what I was meant to do! I showed up to work early the first day. As luck would have it, I was on call. What this meant is that my first day of work would last 36 hours with very little sleep. The chief physician brought me to the third year resident who was handing over his patient’s to me. This was his last day of residency. I will never forget the phrase my chief used when introducing him. He said, “This is John, your taking over his patient’s. Today is his last day of residency. He can’t be hurt anymore!” My thoughts raced…what do you mean “can’t be hurt”? Who was hurting him? It took me about year before I understood what this meant.
In the second year of residency you learn what it feels like to be independent. You do a minimum of 2 months in the ICU where you function without direct supervision. Of course, during the day there are ICU attendings and fellows to help but at night you are on your own.
One night early in my ICU month I was faced with a situation that changed my life. One of my patients had severe respiratory problems and required to be placed on a ventilator. He was an elderly man and we weren’t completely sure of what was wrong with him. I paged the anesthesia person on call to help me intubate him in case I had problems and then I got started.
But things went terribly wrong. I couldn’t get the endotracheal tube in! I kept trying but it was useless. Furthermore, the anesthesiologist never came. We paged and paged but he didn’t show up. My anxiety started to rise. As I placed the mask on the patient’s face and delivered life saving breadths, I felt out of control. I could feel the confidence leaving. I struggled for a few minutes and finally another resident was walking by the ICU and came in and helped. After flailing for about 15 minutes we finally got the patient intubated. Within in seconds his blood pressure dropped. We started CPR and injected epinephrine without benefit. The heart monitor went flat…..and within minutes he was gone. I held back the tears and rehashed every moment. Had I moved to fast to intubate him? Had I deprived him of to much oxygen while fumbling to get him on the ventilator? Did I over sedate him? I will never know the answer to any of these questions.
3
The rest of the night was a blur. I didn’t sleep a wink because I was so busy with my other patients. The man’s wife and family came and went. They didn’t seem to have many questions. It wasn’t till the next morning that the phone calls started to come in.
You see…the family was his new wife and step family, he also had three daughters who were unaware of what had happened. I took three calls that morning. I told three young women over the phone that they lost their father. I listened patiently as all three broke down on the phone. I listened to their moaning and wailing. I remembered what it felt like to lose my father. Each call lasted less then 5 minutes. I never met these women in person. I never spoke to any of them again. Each one of them has left an indelible mark on my soul. I have never experienced grief so pure or innocent. And I will always feel responsible for that grief.
And this is what that resident meant by being “hurt”. If you practice medicine long enough you will make mistakes. You may accidentally hurt people. You will work long hours and deal with the bassist human emotions. At some point you either learn to sublimate, learn to move on, or get crushed. When you say that someone can’t be hurt what you are saying is that they can work 36 hours in a row without sleep, deal with not only the annoyances of hospital life, but also the shear fear and sadness, and still at the drop of a dime make critical decisions involving peoples lives. It also means that you learn how to be hard, learn how not to cry. Your drop your emotions and sentimentality to survive. You change who you are.
When I became a physician I unwittingly made this sacrifice for the possibility of the shear good that I could accomplish. I could deal with the stress, the sadness, even the culpability for people’s lives, as long as there was a pot of gold at the end of the rainbow. I could give up the tenderest side of myself, in order to carry on as a physician and not get squashed by my experiences. During residency there really was no place for tenderness!
So that day, in the ICU, amidst the phone calls and the grief I stood at the abyss. I could either let momentum and sadness carry me down or I could step away. At the time, I thought I was choosing life. At that point I didn’t realize that I was lost and that I wouldn’t feel like myself for many years. In fact, I found myself again October 25th, 2004. The day my son was born……..
4
The rest of my career has been rather mundane. I left residency and joined an internal medicine practice. My days are straight forward. I cram as many patients into as few hours as possible to stay afloat. The malpractice crises is a constant worry. Malpractice prices go up. Physicians are forced to see more patients in less time to cover overhead. The quality of care goes down. There are more law suits…..and the circular trend continues.
People are less happy with their doctors. I often find my patients to be angry and distrustful before they even meet me. There is a constant barrage of paperwork for what seems to be useless reasons. I am constantly being questioned by insurance companies on why I am ordering certain tests and whether I am making the right decision. I so rarely feel like I am helping people!
Physicians are also changing. Because of the poorer income, decreased respect in the community, and family obligations…..they are becoming less responsible for their patient’s well being. The days of your physician meeting you at the emergency late at night in times of need is gone. Most young physicians believe that after the work day is over….their patients are someone else’s concern.
And I believe I would have been okay with this except my world radically changed on Oct 25th, 2004. When my son was born I became a different person. When I looked into his eyes all the barriers that I had erected since that horrible day in the ICU came down. I had found myself again. After years I could feel the warmth return. I could cry again. I could love again. I didn’t have to protect myself any more.
So why was I staying in medicine? It clearly wasn’t making me happy! Why did I give up an important part of myself for a profession that promised so much and delivered so little? Where had I gone wrong?
And what does this say about the state of healthcare today? I had come into this profession with the hopes of helping humanity. I had trained at some of the top institutions in the world. I had received various awards both for academic rigor as well as patient care. I was considered bright, caring, and hardworking. These are qualities you would suspect would make a great physician. But they don’t! And that is the problem.
The story that I told myself about my life had changed. My father’s death had brought me to a profession which I eventually would not like. As my son was born I would come to this conclusion and leave medicine. I could change in time to teach him what is really important. And change I surely had.
But in my heart of hearts, I really tell myself a whole different story. Maybe I truly was meant to be a physician and help humanity and that it wasn’t me at all but medicine……. medicine that had changed.
Either way I realize it is time to change my way of thinking. Who I am and who I will be was neither a result of my father dyeing nor that horrible night in the ICU. It’s time I stopped looking for a cosmic truth in my father’s death and accepted it for what it was….A sad tragedy that will neither define me nor hold me back. It’s time for me to take responsibility and embrace….
Who I have become.
We tell ourselves the stories about our lives that make it bearable….our better yet magical, mystical.
When my father died unexpectedly, when I was seven, I had no words or stories that made sense. How could I explain how this loving father of three and devoted husband could be taken from this earth so quickly and with so little warning. It was a question that puzzled me throughout childhood.
As I grew older I unconsciously formulated the answer to this question. You see…my father died when I was seven years old. At this age, he was my idol. I wanted to be just like him. I copied his movements, his words, and of course I wanted to be a doctor too. My father was a highly respected oncologist and often treated the sickest people. He had received many accolades as well as the love and respect of his patients.
I figure, if he had lived longer, I may have outgrown this period. Maybe I would have reached an age where we fought more or I might have become disillusioned with him. Maybe I would have changed my mind and wanted to be a sports star or a policeman. Who knows? The point is this idea of being a doctor stuck with me. And it carried me.
It carried me through a learning disability; it carried me through a move. It carried me through successes and failures. It created a confidence that never questioned if…only questioned when.
That story made sense. My father’s death, tragic as it was, made concrete in me the idea of becoming a physician. And by doing this I would carry on the tradition and touch countless lives. From his death would come rebirth and renewal. I would help people….I would save lives. I would turn my sadness into good and beauty.
It almost pains me to read this last line. If I had known then how far this was from the truth………………………………
2
When I started residency training in July of 1999 I felt relatively confident. After all, this is what I was meant to do! I showed up to work early the first day. As luck would have it, I was on call. What this meant is that my first day of work would last 36 hours with very little sleep. The chief physician brought me to the third year resident who was handing over his patient’s to me. This was his last day of residency. I will never forget the phrase my chief used when introducing him. He said, “This is John, your taking over his patient’s. Today is his last day of residency. He can’t be hurt anymore!” My thoughts raced…what do you mean “can’t be hurt”? Who was hurting him? It took me about year before I understood what this meant.
In the second year of residency you learn what it feels like to be independent. You do a minimum of 2 months in the ICU where you function without direct supervision. Of course, during the day there are ICU attendings and fellows to help but at night you are on your own.
One night early in my ICU month I was faced with a situation that changed my life. One of my patients had severe respiratory problems and required to be placed on a ventilator. He was an elderly man and we weren’t completely sure of what was wrong with him. I paged the anesthesia person on call to help me intubate him in case I had problems and then I got started.
But things went terribly wrong. I couldn’t get the endotracheal tube in! I kept trying but it was useless. Furthermore, the anesthesiologist never came. We paged and paged but he didn’t show up. My anxiety started to rise. As I placed the mask on the patient’s face and delivered life saving breadths, I felt out of control. I could feel the confidence leaving. I struggled for a few minutes and finally another resident was walking by the ICU and came in and helped. After flailing for about 15 minutes we finally got the patient intubated. Within in seconds his blood pressure dropped. We started CPR and injected epinephrine without benefit. The heart monitor went flat…..and within minutes he was gone. I held back the tears and rehashed every moment. Had I moved to fast to intubate him? Had I deprived him of to much oxygen while fumbling to get him on the ventilator? Did I over sedate him? I will never know the answer to any of these questions.
3
The rest of the night was a blur. I didn’t sleep a wink because I was so busy with my other patients. The man’s wife and family came and went. They didn’t seem to have many questions. It wasn’t till the next morning that the phone calls started to come in.
You see…the family was his new wife and step family, he also had three daughters who were unaware of what had happened. I took three calls that morning. I told three young women over the phone that they lost their father. I listened patiently as all three broke down on the phone. I listened to their moaning and wailing. I remembered what it felt like to lose my father. Each call lasted less then 5 minutes. I never met these women in person. I never spoke to any of them again. Each one of them has left an indelible mark on my soul. I have never experienced grief so pure or innocent. And I will always feel responsible for that grief.
And this is what that resident meant by being “hurt”. If you practice medicine long enough you will make mistakes. You may accidentally hurt people. You will work long hours and deal with the bassist human emotions. At some point you either learn to sublimate, learn to move on, or get crushed. When you say that someone can’t be hurt what you are saying is that they can work 36 hours in a row without sleep, deal with not only the annoyances of hospital life, but also the shear fear and sadness, and still at the drop of a dime make critical decisions involving peoples lives. It also means that you learn how to be hard, learn how not to cry. Your drop your emotions and sentimentality to survive. You change who you are.
When I became a physician I unwittingly made this sacrifice for the possibility of the shear good that I could accomplish. I could deal with the stress, the sadness, even the culpability for people’s lives, as long as there was a pot of gold at the end of the rainbow. I could give up the tenderest side of myself, in order to carry on as a physician and not get squashed by my experiences. During residency there really was no place for tenderness!
So that day, in the ICU, amidst the phone calls and the grief I stood at the abyss. I could either let momentum and sadness carry me down or I could step away. At the time, I thought I was choosing life. At that point I didn’t realize that I was lost and that I wouldn’t feel like myself for many years. In fact, I found myself again October 25th, 2004. The day my son was born……..
4
The rest of my career has been rather mundane. I left residency and joined an internal medicine practice. My days are straight forward. I cram as many patients into as few hours as possible to stay afloat. The malpractice crises is a constant worry. Malpractice prices go up. Physicians are forced to see more patients in less time to cover overhead. The quality of care goes down. There are more law suits…..and the circular trend continues.
People are less happy with their doctors. I often find my patients to be angry and distrustful before they even meet me. There is a constant barrage of paperwork for what seems to be useless reasons. I am constantly being questioned by insurance companies on why I am ordering certain tests and whether I am making the right decision. I so rarely feel like I am helping people!
Physicians are also changing. Because of the poorer income, decreased respect in the community, and family obligations…..they are becoming less responsible for their patient’s well being. The days of your physician meeting you at the emergency late at night in times of need is gone. Most young physicians believe that after the work day is over….their patients are someone else’s concern.
And I believe I would have been okay with this except my world radically changed on Oct 25th, 2004. When my son was born I became a different person. When I looked into his eyes all the barriers that I had erected since that horrible day in the ICU came down. I had found myself again. After years I could feel the warmth return. I could cry again. I could love again. I didn’t have to protect myself any more.
So why was I staying in medicine? It clearly wasn’t making me happy! Why did I give up an important part of myself for a profession that promised so much and delivered so little? Where had I gone wrong?
And what does this say about the state of healthcare today? I had come into this profession with the hopes of helping humanity. I had trained at some of the top institutions in the world. I had received various awards both for academic rigor as well as patient care. I was considered bright, caring, and hardworking. These are qualities you would suspect would make a great physician. But they don’t! And that is the problem.
The story that I told myself about my life had changed. My father’s death had brought me to a profession which I eventually would not like. As my son was born I would come to this conclusion and leave medicine. I could change in time to teach him what is really important. And change I surely had.
But in my heart of hearts, I really tell myself a whole different story. Maybe I truly was meant to be a physician and help humanity and that it wasn’t me at all but medicine……. medicine that had changed.
Either way I realize it is time to change my way of thinking. Who I am and who I will be was neither a result of my father dyeing nor that horrible night in the ICU. It’s time I stopped looking for a cosmic truth in my father’s death and accepted it for what it was….A sad tragedy that will neither define me nor hold me back. It’s time for me to take responsibility and embrace….
Who I have become.
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