We all yearn for something. We strive for that which is just out of reach.
The dreams of childhood are infinite. Unhindered by the shackles of the adult brain, the young mind believes that if it can be imagined, then it can be done. My son's room becomes a library with shelves of homemade books and irregular paper check out cards. The backyard will be my daughter's swimming pool and she digs relentlessly at the ground in front of the garage. For every barricade there is an alternate route. This is the joyous frolic of the first decade. The exuberance of youth is undeterred by the adult concept of possibility.
The yearnings of the middle aged are restless and hurried. We contemplate our accomplishments and recognize that we are young no more. The blood flows through our chest hungrily. The time to make our mark is receding as the sands of the hour glass mercilessly make their pilgrimage. We are vaguely aware of the nagging voices that follow us into our bed at night. They whisper. That book is still unwritten. That promotion will go to someone else. That inheritance is fading into the slop of a bad economy. This is a time of unfulfilled potential.
The sorrow of the elderly is palpable as they walk into my office. Under the weight of their failing bodies lies the discontent of moments lost. It is too late to reconnect with that unrequited love or mend the fence that was so carelessly broken. The heart, however, refuses to lie dormant. The promise of better health, new accomplishments, and continued adoration refuses to pause for human frailty.
To live is to hope.
To hope is to dream.
To dream is to breath.
I have watched people die. I have hovered in doorways and sat at bedsides as the humanness has faded leaving a mass of inanimate tissue. There is a time of struggle where breaths are uneven and labored. Voices are raspy and mouths are dry. This may last for minutes or days.
Yet, without a doubt, at the pinnacle of the dying process there is often a moment of calm. The chest moves evenly and the facial muscles unclench. It is in this moment that I wonder if we can let go of the persistent longing of the living. The sickly pause for clarity and peace before they pass on to the unknown. For once they are still and become one with their surroundings.
Maybe this is the message of the dying. That in letting going of perpetual striving, we may find the acceptance that so eludes us in life.
As I leave the room to write the death note, I vow that I will learn the secret of stillness. But in the seconds that follow, I smirk at my own folly.
Even in this I am still very much alive,
for I have started to strive again.
Thursday, May 31, 2012
Wednesday, May 30, 2012
I'm Not A Doctor, But I Play One On TV
If the government was a physician, it wouldn't be an ordinary doctor like you or I. It would be a sexy actor like the ones we see on those medical melodramas that have become so popular over the last few years. His hair quafed, his jacket pressed and free of stains, and his manor confident he would rush into the trauma bay. As the beeping moniter flat lines, he would sweep the nurses and residents out of the way, grab the paddles, and shock the poor patients heart back to life. The wife and children would rush in and profess love to their newly awakened father. And the super cute head nurse would glance appreciatively at our hero and wink with not so subtle romantic overtones.
Of course, any one remotely involved in health care knows that this is a farse. Wipe away the syrupy made for TV moment and what we are left with is one simple medical fact. You don't shock asystole, it's useless. Such subtleties are often lost on those who shape today's health care policy. And who could blame them? Most are politicians, administrators, or physicians who have long forgotten the practice of medicine.
Given the set of circumstances, the ACA is more sophisticated than it first appears. In fact, much credit must be given for the emphasis on demonstration projects. This is basic scientific method at it's best. Try a bunch of ideas and see which stick. I couldn't be more in agreement.
To Medicare's great embarrassment, recent demonstration projects have shown little measurable benefit for the lynch pins of health care reform: pay for performance and patient centered medical homes. There is no doubt in my mind that the same will eventually occur with ACO's. The problem arises, however, that in Washington, political expedience often carries more weight than courage. In other words, it may be of no benefit whatsoever to shock asystole, but when the film is rolling, the defibrillator paddles are charged and ready. It's a million dollar fundraising moment. Politicians like these.
But when the lights are turned down and the cameras shut off, we are left with a doctor who knows nothing of the practice of medicine and a health care system wrought with perverse incentives.
We need the real thing.
Not just someone who plays a doctor on TV.
Of course, any one remotely involved in health care knows that this is a farse. Wipe away the syrupy made for TV moment and what we are left with is one simple medical fact. You don't shock asystole, it's useless. Such subtleties are often lost on those who shape today's health care policy. And who could blame them? Most are politicians, administrators, or physicians who have long forgotten the practice of medicine.
Given the set of circumstances, the ACA is more sophisticated than it first appears. In fact, much credit must be given for the emphasis on demonstration projects. This is basic scientific method at it's best. Try a bunch of ideas and see which stick. I couldn't be more in agreement.
To Medicare's great embarrassment, recent demonstration projects have shown little measurable benefit for the lynch pins of health care reform: pay for performance and patient centered medical homes. There is no doubt in my mind that the same will eventually occur with ACO's. The problem arises, however, that in Washington, political expedience often carries more weight than courage. In other words, it may be of no benefit whatsoever to shock asystole, but when the film is rolling, the defibrillator paddles are charged and ready. It's a million dollar fundraising moment. Politicians like these.
But when the lights are turned down and the cameras shut off, we are left with a doctor who knows nothing of the practice of medicine and a health care system wrought with perverse incentives.
We need the real thing.
Not just someone who plays a doctor on TV.
Monday, May 28, 2012
The Roles We Play
The last time Charlie's grandmother called before a visit, it was to let me know that he had a "special" friend. She might not of said it directly, but I knew it was time to have a talk about the birds and the bees, STD's, and birth control. He may have been in his mid thirties, but he functioned like a teenager.
Charlie never really knew his parents. His father jumped ship when his mental shortcomings began to manifest during elementary school. A short time later his mother died from pneumonia, and he moved in with his grandparents. There were a few years of independent living in an apartment complex, but he returned to help around the house when his grandfather passed away.
Years ago, Charlie was labeled as "slow" before we had the nomenclature for the complex range of mentally challenging diseases that exists today. An accordingly, anyone who spent a few minutes talking to him could tell that something was different. A longer conversation, however, would reveal that a thinking, feeling person was present behind the facade that he had been labeled with. He held a job at the local grocery store for more than a decade, and was even named employee of the year a few times. He was fiercely protective of his grandmother and was a loyal friend.
Taking care of Charlie was a pleasure. He came to see me regularly and followed directions when given. He had a plethora of minor problems which we dealt with on an ongoing basis. It was the kind of visit I looked forward to.
Charlie entered the exam room in a button down shirt and blushed as he handed me the neck tie. His grandmother's vision had become to poor to help him do such things anymore. I stood a few inches behind him as we stared into the mirror. I took his hands in mine and gently guided him through the motions. By the end of the fifteen minute appointment, he could tie it by himself. I made him promise to take pictures and bring them to the next visit.
As a physician, I fulfill many roles for my patients. To some, I am like a son doting over his parent's every ache or pain. To others, I am a comrade who lends an ear during difficult times.
And occasionally, momentarily, I get to fill the space of a father who left long ago.
Being the product of a single parent family, it's a role I particular cherish.
Charlie never really knew his parents. His father jumped ship when his mental shortcomings began to manifest during elementary school. A short time later his mother died from pneumonia, and he moved in with his grandparents. There were a few years of independent living in an apartment complex, but he returned to help around the house when his grandfather passed away.
Years ago, Charlie was labeled as "slow" before we had the nomenclature for the complex range of mentally challenging diseases that exists today. An accordingly, anyone who spent a few minutes talking to him could tell that something was different. A longer conversation, however, would reveal that a thinking, feeling person was present behind the facade that he had been labeled with. He held a job at the local grocery store for more than a decade, and was even named employee of the year a few times. He was fiercely protective of his grandmother and was a loyal friend.
Taking care of Charlie was a pleasure. He came to see me regularly and followed directions when given. He had a plethora of minor problems which we dealt with on an ongoing basis. It was the kind of visit I looked forward to.
Charlie entered the exam room in a button down shirt and blushed as he handed me the neck tie. His grandmother's vision had become to poor to help him do such things anymore. I stood a few inches behind him as we stared into the mirror. I took his hands in mine and gently guided him through the motions. By the end of the fifteen minute appointment, he could tie it by himself. I made him promise to take pictures and bring them to the next visit.
As a physician, I fulfill many roles for my patients. To some, I am like a son doting over his parent's every ache or pain. To others, I am a comrade who lends an ear during difficult times.
And occasionally, momentarily, I get to fill the space of a father who left long ago.
Being the product of a single parent family, it's a role I particular cherish.
Saturday, May 26, 2012
The Shores Of My Insides
I have always been able to sense pain and suffering. As a child I visioned it as a light that emanated from others bosoms and I was the beacon. It was not something I saw so much as felt.
I wonder if I got that from my father. The poor soul, he knew he would die young. I, on the other hand, have always innately felt that I would die at an old age after witnessing the passing of all those I cared for. It was not that I felt this a burden, it was just the load that I was uniquely built to carry.
As I've grown older, I've honed my skills. Conversations with strangers end in tears as I am able to divine what they need from me. My choice of career is fitting when seen through this lens. But even in medicine, I have migrated away from the young and healthy and have landed square in the middle of illness and dying.
Sometimes I have delusions of grandeur. I picture many like me have been placed among our populations. We act like vessels accepting the pain and suffering that others must deposit. Unlike those others, I am not destroyed by this sadness. Conversely, it fills me up. As the raging waves of the ocean crash against the shores of my insides, the waters eventually calm and the tide recedes.
And I am empty once again.
Like a banker without money, waiting for the next deposit.
I wonder if I got that from my father. The poor soul, he knew he would die young. I, on the other hand, have always innately felt that I would die at an old age after witnessing the passing of all those I cared for. It was not that I felt this a burden, it was just the load that I was uniquely built to carry.
As I've grown older, I've honed my skills. Conversations with strangers end in tears as I am able to divine what they need from me. My choice of career is fitting when seen through this lens. But even in medicine, I have migrated away from the young and healthy and have landed square in the middle of illness and dying.
Sometimes I have delusions of grandeur. I picture many like me have been placed among our populations. We act like vessels accepting the pain and suffering that others must deposit. Unlike those others, I am not destroyed by this sadness. Conversely, it fills me up. As the raging waves of the ocean crash against the shores of my insides, the waters eventually calm and the tide recedes.
And I am empty once again.
Like a banker without money, waiting for the next deposit.
Friday, May 25, 2012
The Opacification Of Intent
There was a time when the humble physician traveled to each patients home. Care was rendered at poorly lit bedsides with a stethoscope, a pat on the back, and whatever medications could be fit into a small black bag. Payment was cash, or barter, or services were provided for free. As the doctor packed his tools and left the house a few ticks past midnight, there was no questioning the nature of the man who walked through the door. The intentions of the profession were abundantly clear.
Years later, medical science has advanced far past the boundaries of these so called dark ages. People are living longer, healthier lives. Although the scourge of disease is being successfully battled on every front, the doctor-patient relationship is more fractured than ever. We have lost the position of our brother's keeper. Suspicion and anger have become empathy's uncomfortable bedfellow.
So what has changed? The doe eyed medical student who cautiously peers into the room of her first hospital patient is lauded. This poor soul has emptied her bank account and devoted countless hours to master the self serving mistress of knowledge. The frail, emaciated, cancer riddled patient reaches his hand out to her, even as his body is failing. For they are comrades who struggle and suffer together. No one doubts what drives the student's heart.
As one advances into practice, a metamorphosis occurs, and thus begins the opacification of intent. A geographic barrier is formed when a patient has to travel to the physician's office. Medicare and the modern insurance complex cause an economic barrier as the patient is required to disclose payment information even before an appointment is made. A physical barrier is placed between doctor and patient as we hide behind our electronic medical record and use technology in place of touch.
We have allowed for the institutionalization of empathy and we suffer the consequences.
Yet I still believe our intentions are pure.
Years later, medical science has advanced far past the boundaries of these so called dark ages. People are living longer, healthier lives. Although the scourge of disease is being successfully battled on every front, the doctor-patient relationship is more fractured than ever. We have lost the position of our brother's keeper. Suspicion and anger have become empathy's uncomfortable bedfellow.
So what has changed? The doe eyed medical student who cautiously peers into the room of her first hospital patient is lauded. This poor soul has emptied her bank account and devoted countless hours to master the self serving mistress of knowledge. The frail, emaciated, cancer riddled patient reaches his hand out to her, even as his body is failing. For they are comrades who struggle and suffer together. No one doubts what drives the student's heart.
As one advances into practice, a metamorphosis occurs, and thus begins the opacification of intent. A geographic barrier is formed when a patient has to travel to the physician's office. Medicare and the modern insurance complex cause an economic barrier as the patient is required to disclose payment information even before an appointment is made. A physical barrier is placed between doctor and patient as we hide behind our electronic medical record and use technology in place of touch.
We have allowed for the institutionalization of empathy and we suffer the consequences.
Yet I still believe our intentions are pure.
Thursday, May 24, 2012
Disruption, I See Great Change
We talk of disruptive change in health care as a tectonic cataclysm. We're hanging by the moment for that one innovation that will flip flop the practice of medicine and bring better, more efficient care. But if you ask the poor lowly physician struggling on the front lines, we might tell you something different. We are suffering through a sustained, insidious, devolution. I see great change.
Reform takes place in fits and sputters. Regulations are made and then remade. The product of the governmental assault on the cost of health care is a series of forms and check marks. Who better to be responsible for such minutia then the wayward primary care physician. The same beleaguered professional whose numbers are dwindling in direct relation to their pay and inversely related to their work load. With the passage of the ACA the paperwork has already increased. The time spent typing away at a computer is multiplying. Is care any better?
I see great change. Physicians are looking for a way out. They are becoming businessman, social media entrepreneurs and commentators, writers, reformers, and career coaches. They are retiring early and cutting their hours. I spend less time in the clinic than ever before. Each year I replace some of my office time with non clinical revenue generating activities. The joy of patient care is being overshadowed by regulation. We are quietly and incrementally bowing out.
The patient narrative is fracturing. Primary care physicians are using hospitalists. Patient centered medical homes and large medical groups are favoring speed of access over continuity of care. A patient no longer has one physician but a team of doctors working on their behalf. Unfortunately, as opposed to group think, what usually happens is that each provider knows strikingly little about the patient. Tests are repeated, stories are retold and modified, there is no longer a holder of knowledge. A persons narrative not only heard but experienced over years of joint interactions and communications. We are losing our connection. Care is suffering.
In reality, the disruption we are looking for has been occuring in a sustained fashion for years.
Are we ready to deal with the consequences?
Reform takes place in fits and sputters. Regulations are made and then remade. The product of the governmental assault on the cost of health care is a series of forms and check marks. Who better to be responsible for such minutia then the wayward primary care physician. The same beleaguered professional whose numbers are dwindling in direct relation to their pay and inversely related to their work load. With the passage of the ACA the paperwork has already increased. The time spent typing away at a computer is multiplying. Is care any better?
I see great change. Physicians are looking for a way out. They are becoming businessman, social media entrepreneurs and commentators, writers, reformers, and career coaches. They are retiring early and cutting their hours. I spend less time in the clinic than ever before. Each year I replace some of my office time with non clinical revenue generating activities. The joy of patient care is being overshadowed by regulation. We are quietly and incrementally bowing out.
The patient narrative is fracturing. Primary care physicians are using hospitalists. Patient centered medical homes and large medical groups are favoring speed of access over continuity of care. A patient no longer has one physician but a team of doctors working on their behalf. Unfortunately, as opposed to group think, what usually happens is that each provider knows strikingly little about the patient. Tests are repeated, stories are retold and modified, there is no longer a holder of knowledge. A persons narrative not only heard but experienced over years of joint interactions and communications. We are losing our connection. Care is suffering.
In reality, the disruption we are looking for has been occuring in a sustained fashion for years.
Are we ready to deal with the consequences?
Wednesday, May 23, 2012
Refundable?
It was a laughably small amount-something like ten or fifteen dollars. But when the customer service agent for the local phone company told me that she wouldn't refund my money, something snapped. My heart started to race like a turbine engine, and I could feel the warmth rising up through my face and landing square into my temples. My hands curled around the pager strapped to my belt loop, and the sweat began to drip down my forehead.
As I jumped off the bed and began to pace, my wife stared up at me from the other side of the room. A rumble started in the bowels of my chest and regurgitated through my mouth. At first the words sputtered out in in a measured but gruff tone. Although the operator was trying to back down, the eruption, once begun, was becoming uncontrollable. I was a pit bull.
My voice shook with anger as I delivered a series of high pitched verbal barks. The sentences became paragraphs, the paragraphs pages, and the pages congealed into a verbally abusive story. My body split in half. The calm side watching the explosion and picturing some poor operator sitting with the phone purposefully turned away from her ear. The other side, fire and brimstone, was too busy blathering at the mouth to recognize the absurdity of the situation.
This might have gone on for hours if I hadn't paused to take a breath. My bloated face, sweaty brow, and bulging eyes did nothing to diminish the acuity of my hearing. In the brief moment of silence between curses, I heard the most small and inconsequential sound. A sniffle. A gasp. The delicate weeping of a stranger.
Six months into residency, I had become a radically different person. Many would blame the transformation on the brutality of our training programs. But I think we are missing the point. The uncontrollable rage comes from somewhere more primal. It's more endemic to the professional as a whole. we bang our heads against the wall to knock on the door because our hands can be so useless.
I lost a little part of my soul that day. And the price?
A ten dollar refund from the telephone company.
As I jumped off the bed and began to pace, my wife stared up at me from the other side of the room. A rumble started in the bowels of my chest and regurgitated through my mouth. At first the words sputtered out in in a measured but gruff tone. Although the operator was trying to back down, the eruption, once begun, was becoming uncontrollable. I was a pit bull.
My voice shook with anger as I delivered a series of high pitched verbal barks. The sentences became paragraphs, the paragraphs pages, and the pages congealed into a verbally abusive story. My body split in half. The calm side watching the explosion and picturing some poor operator sitting with the phone purposefully turned away from her ear. The other side, fire and brimstone, was too busy blathering at the mouth to recognize the absurdity of the situation.
This might have gone on for hours if I hadn't paused to take a breath. My bloated face, sweaty brow, and bulging eyes did nothing to diminish the acuity of my hearing. In the brief moment of silence between curses, I heard the most small and inconsequential sound. A sniffle. A gasp. The delicate weeping of a stranger.
Six months into residency, I had become a radically different person. Many would blame the transformation on the brutality of our training programs. But I think we are missing the point. The uncontrollable rage comes from somewhere more primal. It's more endemic to the professional as a whole. we bang our heads against the wall to knock on the door because our hands can be so useless.
I lost a little part of my soul that day. And the price?
A ten dollar refund from the telephone company.
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