Are We Witnessing The Death of the Modern-Day Physician?

Pamela Wible recently wrote a provocative article on KevinMD regarding physician suicide. In the seminal piece, she conducts “psychological autopsies” on 3 physicians in training who had taken their lives. She searches for answers and suggests solutions for what has become a problem of epidemic proportions. Whereas her focus on the individual is laudable and instructive, I would like to apply her technique to the profession as a whole. While some physicians are committing suicide or becoming addicted to drugs, others are leaving in less-devastating but still consequential manners: early retirement and nonclinical career paths. To many, it feels like a most-celebrated calling is laboring through its last breaths. I stand here today, scalpel in hand, ready to conduct an autopsy of an honorable profession. Are we witnessing the death of the modern-day physician?

See the rest of my post at The Medical Bag.

Is Less Actually More? Should Your Physician Be A Plumber Or A Violinist?

It seems everywhere you look in health care today, some consultant is telling you that "less" is actually "more".  Less care leads to more quality.  Less expense brings better outcomes.  Nurse practitioners with less training are more cost effective.  Less work hours for residents builds a safer hospital environment.

Never in our entire history have we gotten so much for so little.

A recent article on KevinMD by Arshya Vahabzadeh asks whether shortening medical school is a good idea.  A fairly nuanced piece, a balanced viewpoint is given.  I was particularly interested in the conversation surrounding time-based verse competency-based assessment.  In many ways, I think it is helpful to view the changes overtaking medicine through this lens.  

In the old way of thinking, medicine was an art.  Like learning to play the violin, mastery was a distant mountain with many peaks and valleys.  The climber learned technical skills in the beginning: how to hold the bough, how to read music from the page.  These technical skills, however, were the foundation of knowledge, but not mastery unto itself.

Mastery came when technical skills were married with unfathomable degrees of practice, luck, and passion.  No one in their right mind would tell the musical genius to put down the violin for fear of over practicing.  No one would tell them that less practice is actually more.  And so it is with writing, and singing, and even mathematics.  Technical abilities can only take one so far down the road.  There is something intangible that is only gleaned from exhaustive repetition.  

The new view of medicine is that providers are technicians.  More like plumbers.  Now, I have no problem with plumbers, but once you learn how to change a toilet or unclog a pipe, there are only so many variations.  If a plumber can demonstrate their competency in such fields, there is little need to endure more training.  Hence the training to be a plumber, to date, has been less arduous than that of your typical doctor.  

The educational model for physicians today is becoming more skills based.  We now have teams, checklists, and electronic warnings that allow physicians in training to reach competency quickly.  They become facile at entering data and awaiting a clinical guideline to pop up on their computer screen.  Care plans are less individual and creative, and more standardized.  

If this paradigm becomes reality, who really needs a fourth year of medical school?  Or possibly a third?

But, I bet the average patient will not be so happy as these changes take hold. 

At one's most vulnerable moment expecting a great concerto, a virtuoso, how sad to receive a toilet plunging instead.

Is Maintenance Of Certification a Tipping Point? #DisagreeMOC

Physicians are docile.  We are programmed to put the greater good above our own.  We train mercilessly, work tirelessly, and bend faithfully at the alter of those we have vowed to heal.  This is our birthright.  This is the covenant we signed in our own blood when we took our healing oath.  Decry us as they will, no one becomes a physician to make money.  No one devotes decades of education and hardship to take advantage of the system.  There are just too many easier ways to defraud.   Easier ways to earn a buck.

Accordingly, physicians have been far too accommodating.  Rather than rock the boat, we have accepted the spew and encroachment that has come from almost every direction.  Lawyers will sue.  Politicians will mandate and legislate.  Technologists will code and program.

And by and large, we have accepted each bitter pill as it has sucked away the very marrow of enjoyment and professionalism of our field.  We have spent our own precious hours learning how to document better, feeding a torte system that shows no signs of being consumed by it's own wanton wastefulness.  We have slaved over relentless forms and check marks,  each new piece of paper the love child conceived in an orgy of governmental vigor.  And we have hunkered down in front of computer systems stoked by nonsensical technology ignoring the very patients they were created to serve.

The result has been a great emigration away from clinical medicine.  Early retirement. Suicide.  Physicians are fleeing to safer ground.  Better to leave, say the humble and meek, then to fight on the bloody battle field.  The death of a once revered profession is a fate that is all but sealed.  Of course, there is a glut of youths waiting to become medical students.  But the medicine they practice will be barren of the art we so often admire today, full of clinical pathways, and largely driven by less trained assistants and secretaries.

The government has mandated it to be so.  The lawyers, politicians, and journalists concur.  Health care administrators salivate at that juicy stake that has just been stolen off the plate of the so called "providers" and dropped into their lap.

The future had all but been written.  The pathway marked and measured.  The funeral arrangements made.

Except.

Except a tiny overreaching mistake by a greedy group of "once" doctors trying to lap up a small taste of the gravy train.  The American Board of Internal Medicine (ABIM) in an effort to boost revenues announced it's new Maintenance of Certification (MOC) requirements.  These largely unproven, waste of time and money efforts, did something that all the legislation and finger pointing on capitol hill had largely avoided.

It awoke the heart of the lion in the poor bleating body of the lamb.

Dr. Wes Fisher and a number of his cardiologist associates exploded the internet with opinion pieces and exposes regarding the ABIM, conflicts of interests, and the lack of data supporting such testing.  These lone voices have broken the silence of the long barren field of physician advocacy.  The visceral response amongst the populace has grown steadily over the last few months.

I believe we have come to a tipping point.

Maintenance of Certification has become the spark that has finally ignited the beleaguered physician. Faced with a nonsensical health care system mired in administrative minutia, we have found a rallying cry that symbolizes all that trampling we have endured over the last few decades.  The hope rings out from city to city, that if we can just conquer MOC, than maybe meaningful use will be next. Maybe torte reform is on the horizon.  Maybe, just maybe, we can form our own seats at the table instead of be served up for the main course.

We have a number of road blocks standing in our way.  Any practicing physician, not being paid by the ABIM, can tell you that MOC is both a waste of time and money.  However, it is often a requirement of credentialling at our hospitals.  Furthermore, it is only a matter of time before it becomes one of the quality measurements used by the government to determine payment.  These facts must be uncoupled in order to move forward.

I think we must speak clearly with a united voice.

The ABIM board of trustees should be fired, all conflicts of interest must be disclosed.
The MOC should be abolished or radically changed.
The AMA and the ACP should pressure the ABIM for these changes or we should withhold our membership fees.

***

Will this be the death knell of our proud profession or the shock that brings us back to life?  Only time will tell.

I disagree with the MOC.

#DisagreeMOC

To Be Noticed Immediately and Judged Subconsciously

I think I will carry two things with me from this experience.

My body dropped.  Almost instantaneously.  One minute I was jogging next to my wife, the next my mouth and nose were hitting the pavement.  I must have slipped, my foot must have caught. There was no time to anticipate the pain, not even a millisecond to reach out my arms to cushion the blow.  Moments later, I felt the sting upon my upper lip and the taste of blood.  I rolled back and forth on the ground trying to shake off the searing heat arising from my face.

My wife dropped to the ground to comfort me.  Pedestrians stopped inquisitively and pulled out their mobile phones ready to call an ambulance.  I stood up shakily and composed myself enough to ward off the attention.  And we hobbled home, my wife and I.  The blustery wind permeating my light jacket and sending a chill through my aching bones.

At home, I surveyed the damage as my children peered around the bathroom door cautiously.  My front tooth was chipped.  My face was bruised, and the skin beneath my nostril was irritated and angry.  Looking in the mirror, it appeared as if my nose was bleeding, although when I wiped the area there was scant debris on the tissues.  My hands were swollen and sore.

My Friday dinner plans were ruined.  We ordered a pizza, sat on the couch, and watched a movie.  I gingerly maneuvered the crust around my mouth avoiding the front teeth that were tender and numb.  I fell asleep immediately, and woke up early next morning ready to go to work.

Almost every part of my body ached.  My swollen hands screamed as I turned on the sink faucet.  My chest collapsed as I picked up my work bag.  And my lips were still puffy and bruised with the ever present appearance of nasal bleeding.

I hobbled into the car and sped towards the hospital.  Every left turn required a twisting of the wrist that sent lightning up my arm.  As I pulled into a parking spot at the medical center,  a spasm of fear over took me.  Once glance in the mirror confirmed my worst fears.

I looked funny.  All day long I would have to explain what was going on with my face. All day I would see the inquisitive looks before the words formed on people's mouths.  I was abnormal.  I was a monster.

Forty eight hours later, my tooth has been fixed and the bruising has abated.  I still have pain when I complete almost any movement, but it's getting better.

But for a moment, I was the outcast.  Distorted and bruised, I had a small taste of what it feels like to  be disfigured.  To be noticed immediately and judged subconsciously.

And to be in pain.  Not the minor aches that we all feel from time to time.  True pain.  The kind that makes you aware of every movement.  Every step.

In a matter of days, I'll be completely back to normal.

Many of my patients, however, continue to struggle with maladies that are far less kind.

Idolatry

Julie was lost in thought.

Her right pointer finger slowly traced the edges of the metallic trinket.  It was tucked far enough into her pant pocket that only the longest digit could reach.  Back and forth, her hand moved caressingly, pausing from time to time to inspect any irregularity, any imperfection.  In such a manner Julie built a mental image of the old forgotten piece of jewelry.  Her hands visually occupied a space that her eyes had long abandoned.

There was not much to the frigid, sterile room  A few rickety chairs. A  worn carpet.  Some posters placed haphazardly on the wall. The smell of bleach wafted through the waiting room and mixed with the alcohol emanating from where the IV had been placed in her forearm.  Julie had grown used to the metallic explosion of iodine assaulting her palate shortly after the injection.  There were all sorts of explanations.  It reminded her of fear.

She drank it in.  Every few months.  Much like her mother had.  Cat scans and blood tests, radiation and chemotherapy.  At least there was action.  Waiting is what slowly killed her mother.  Desperate moments lost in rooms such as these.  Waiting to be poisoned.  Waiting to be irradiated.  Waiting to be informed and then consoled.  If one could string all those moments together side by side, surely there would have been enough time for one last trip to Mexico, or maybe Vegas.

Julie's mother allowed the life to spill out of her in such a pathetic, untidy manner.  She grasped the tarnished cross in her hands.  She never bothered to remove the chain, although it was seldom worn around her neck.  She would clutch openly at the pendant while she waited, until she was called back to the office.  Then she would slip the cross back into her pocket, and hurry after the nurse who most likely had already disappeared behind the cantankerous doorway.

No matter how hard Julie tried, she couldn't stem the flood of memories that threatened to drown.

The night her mother died, her father fastened the necklace on the lifeless chest, haughtily displaying all the agony and fear.  He said it looked nice.

After everyone left, Julie leapt to her feet and snatched the horrid idol from where it lay.  The flimsy chain snapped and disappeared into the murky abyss of the casket.

It was the last time that Julie would ever touch her mother,

or see the hapless chain again.

A Year Of Concierge Medicine

A year ago, I embarked on a voyage at the leading edge of modern-day health care. I abandoned my traditional office-based practice of 2000 patients for a much smaller membership (concierge) model.  My reasons were varied. They mostly focused on the dwindling time and concentration afforded by so-called  “advances” in medicine, such as electronic medical records and the ever-increasing deluge of paperwork that plagues today’s physician. As I begin year 2, I would like to share a few things I have learned...

Please read the rest of my post at The Medical Bag.

Attention #HCSM Meeting Planners. Would You Like Me to Speak At Your Event?

The only thing better than blogging is having the chance to tell one's stories in person.  While I have been asked to speak at a number of events over the years, I have developed a new talk that I am especially itching to give to a live audience.  I expect it will have all the emotion and impact of the DotMed 2013 appearance below.



Details
Topic/Running Title: The Medical Narrative, A Tie That Binds Doctors and Patients
Style: TED style, no visuals, no notes
Content: Narrative heavy, didactic light
Running Time: 15-20 minutes

Requirements
Will accept multiple offers, but will give video rights only to one.
Need a few months in advance to arrange my schedule.
Expenses and stipend to be negotiated.

Please respond by email: grumetjordan(at)yahoo.com

I also blog and speak about personal finance.