Primary Care Shrugged

I remember reading Ayn Rand's Fountainhead as a senior in high school.  I voraciously lapped up every word, every movement of her protagonist, Howard Roark.  My adolescent yearning for identity and integrity meshed well with the book's message.  The black and white morality fit well for one who was unable recognize shades of gray.

My freshman year of college, I read Atlas Shrugged.  And again, I found that Rand's words reverberated deeply in my soul.  I so wanted to believe that the able few drove the motor of the world.  For the rest of the poor slobs, it was either put up or get out of the way.  I was young and very impressionable.

As I grew older and experienced more, I began to change.  The simplistic morality play in Rand's novels started to feel crude.  Sometimes the poor and uneducated suffer their lot in life despite their best intentions.  Sometimes will and ability are just not good enough.  And luck often prevails over skill.  I became an adult and my sensibilities changed.

Strangely, as we talk about the state of health care in America, I find myself coming full circle.  There is whispering about a Primary Care revolution.  The pundits are already starting to critique the next steps of the movement.  Primary Care will arise again and become the lynch pin of a new era.  Affordable, practical, evidence based medicine will follow shortly over the horizon.  We are saved!

But if you ask me.  I think a little differently.

I think Primary Care shrugged long ago.  We just now are beginning to see the effects.

How else do we explain the drop in training in outpatient medicine and family practice?  What other forces explain the overuse of diagnostic testing and high utilization of referrals instead of deep thinking?

Many may have stayed in practice because of economic necessity,

but the heart of the speciality is gone.

In Memoriam

It was a beautiful cool day much like this morning. I pulled into the parking spot recklessly. I was running late, but if I hurried, I might just make it. I grabbed my backpack and slammed the door shut without a second thought. Then my stomach sank. I heard the calm hum of the motor as I reached back for the door. Locked.

I felt the panic swell inside. My sixteen years of experience hadn't yet taught me how to deal with such things as overwhelming embarrassment. How could I have locked the keys in the car with the motor still running? As I stood frozen trying to find a way out of the situation, I heard footsteps behind me.

The women paused momentarily and gently placed her arm on my shoulder.

A little bit of a predicament...huh?

She had known me since birth. Her eldest child was my age. She was friends with my parents. And she had been kind enough to allow me to park at her house because I wasn't old enough to get a parking permit from my high school.

I remember her from childhood. At that time we lived on the same block. Her smile was always comforting. Motherly. And her kitchen usually smelled of something good. Her son and I were best friends once. But time and distance had taken their toll. Now we only ran into each other sparingly.

I was no longer a child, although I felt like a five year old parked in her kitchen waiting for my mom to come pick me up. I felt helpless as she called the police to have my car door opened. She made me hot chocolate while we waited. She neither teased nor chided. When I left she offered to write a note for my teacher. But I refused. I wanted to maintain the little pride I still had.

Over the next 15 years our paths crossed occasionally. My mom would update me on what was going on with her family.

I was busy with college, then medical school, then residency. I finished my training and returned to be a hospitalist at a local hospital. I was feeling young an important,competent, and ready to tackle the world.

I had known that she was diagnosed with lung cancer. Never a smoker, she was one of the unlucky ones.  From time to time I would stop by her room to chat when she was admitted for chemotherapy. We discussed her fears and anxieties. We talked about old times. I was just a friendly visitor to pass the hours.

The last time she was admitted, I made a point of coming early. She was in the hospice program and was dying quickly. I knocked gently on the door and let myself in. I expected to find a room full of people, but instead it was empty. Her family had stepped out briefly for a cup of coffee.

She was resting quietly. She was unconscious and breathing deeply. She had a look that I recognized-the look of someone who was walking her lasts steps through life's unexpected maze. I knew her time was fleeting.

So I sat next to her bed and let her know that I was there. Speaking softly, I leaned forward towards her. I told her that I was sorry for what she was going through. I told her that it was a pleasure knowing her. And then I said goodbye. I placed her hand in mine and promised that I would always remember.

I left the room before the family returned. She died later that day. Inexplicably, I didn't go to the funeral.

I run into her son every now and then. Our lives have taken such different paths, but we still share history. Unlike the people he now meets today, I knew his mother. And this means something.

I don't know why these thoughts came to me this morning as I got out of my car. Why such randomness pops into my head. But I am thankful for them nonetheless.

I will keep the promise I made to her that day.

I will always remember.

Saturday

Daddy, daddy.

My daughter greets me at the door with a wiffle ball cradled in both hands.  My son follows closely with his fingers wrapped around the thin plastic stem below the fat end of a bat.  My wife slips past and kisses me on the cheek as she makes a beeline towards the garage to run errands.  I persuade the kids to follow up the stairs so I can change my rounding clothes for more comfortable shorts.  It's a sunny Saturday morning and the air is still cool.

I clip my pager onto my pants, and curl the blue tooth around my ear.  We rush out the door, and my son and daughter fight over the bat.  They have no interest in the hollow white sphere with the three air holes at the top.  I wait for a moment before intervening.  As I am about to jump between them my pager starts to buzz.

I sit down on the deck and dial the the number to the ICU hesitantly.  I lean on my left hand as my right clenches the ball.  A nurse answers the phone.  After my visit a few hours ago, the patient's blood pressure started to drop and the temperature rise.  I bark a few orders before being interrupted by call waiting and my vibrating pager simultaneously.

I click the call waiting and watch my children.  My daughter has dropped the bat and is now digging in the dirt with a child size trow.  My son has turned on the hose and is sloppily watering the plants.  The pulmonologist is worried.  The lactic acid is elevated and they are about to intubate.  We agree that I should call the cardiologist.  I leave a message with the answering service and dial the ignored number from my pager.

The patient's daughter is frantic.  Her fear and anger are evident in the vibrations of her voice as I strain to hear over my son who is yelling past the fence to the next door neighbor.  I pin the ball under my hand and push downward with increasing power as it rolls forward to escape the compressive force.

We talk about end of life wishes.  We talk of signs and symptoms, probabilities and prognosis.  The out come is too unclear at the moment.  I click over and leave her waiting as I answer the call back from the cardiologist.  He's in the building and will be in the ICU shortly.  They might need to open up the cath lab.

The sweat drips down my brow as the sun rises and the temperature creeps higher.  My son and daughter are crouched in the corner.  I can't see the extent of their mischief.  The ball has picked up dirt from the deck, and is taking on a  brownish black hue.  I throw it against the floor violently, and catch it as it comes racing  towards me.  The patient's daughter has surrendered the phone to the nurse.  The pressure is stabilizing but the sats are starting to drop despite intubation.  The X-Ray tech is on  the way from radiology. 

The nurse then gives the phone to the patient's son.  My daughter has snuck behind me and sticks her finger under my arm.  She laughs devilishly.  I pull back and stare at her malevolently.  I shoe her away with the ball glued to my hand like a a magnet stuck to metal.

The patient's son is despondent.  He wants to withdraw life support.  I ask if his sister is in agreement.  Again, I excuse myself to answer call waiting.

The cardiologist says that it's a no go. 

She's way too unstable.

I click back to the son.  Everyone is in agreement.  Seconds later, I give the nurse orders for a morphine drip.  The tube is removed.  My son is tugging at my arm.  I speak to him distractedly as I look helplessly towards the sky.

Hold on, I'm almost done!

The nurse reports that the monitor has flat lined.  I speak soothingly to the daughter.  My son is becoming more persistent.  He is really pulling on my arm now.

Dad!  Dad!

I hang up the phone and explode in his direction.

What's so important?

I'm frustrated and sweaty, sad and emotionally worn out.  My child becomes sheepish while his sister joins him on the deck.  He won't look me in the eyes. He speaks quietly, almost in a whisper.

Your bleeding!

The wiffle ball has torn open at the seems, and my finger is stuck on the inside.   A trickle of blood stains the pristine white edges.

I look at the precious angelic faces in front of me.

It's been an hour and a half, and I haven't noticed that the temperature has risen to a hundred.  I only now see that my daughter's face is smeared with dirt instead of sunscreen.

It's another Saturday,

and once again I've ignored my children.

Meaningful Abuse

Undoubtedly the most difficult challenge of practicing medicine is the complexity.  There are both elements of IQ as well as EQ.  Because of this, the process of training is marked by a number of hurdles and weeding out periods.  Only a certain number of people pass the premed curriculum.  Those who succeed can get tripped up on MCAT testing.  If ones score are acceptable, so begins the interview process.

Those lucky enough to matriculate into medical school are pushed on every level.  Hours of classes and studying are followed by repeated skills assessments in which a certain percentage always fails.  The clinical years are marked by grueling physical and mental endurance.  The harsh realities of sickness and death, as well as the intense pressure cause not an insubstantial number of students to drop out.

And of course, once the weary student actually graduates, they get plunked on the head by residency.  When a patient enters the office of an attending physician, they step into the workshop of one whose abilities have repeatedly been stretched to the breaking point.  Yet still, few who inhabit the exam room would be called true masters.  In medicine, mastery and perfection are unreachable ideals.

This is why so many of our best and brightest enter the field.  It is like food to the hungry, water to the desert.

So it would take a truly twisted soul to suggest that what's needed in modern day medicine is more complexity.  Somehow, however, this is exactly what the government and reformers are suggesting.

Instead of searching through computer screens, we should be looking people in the eye.

Instead of trying to remember meaningful use criteria, we should be thinking deeply about our patients.

We are taking infinitely complex processes and adding new layers.  We are wasting our scarce resource, brain power, on paper work.  Our numbers may look great, but care is suffering.

That's the funny thing about the term "meaningful".

Perspective is everything.

The Clock Is Ticking

He reclines in his office with his shirt unkempt and bulging from his low riding trousers.  His cup of coffee sits on the desk, but if you look from exactly the right angle, you may imagine it floating from the bulbous pannus that abuts the blotter.  His lab coat is frayed and creased.  A stain lies below the breast pocket, the remnants of a malfunctioning pen.

His voice is confident and gruff.  The steadiness makes one sure that he is used to giving orders without apology.  He fiddles with the phone and taps his feet impatiently.  His eyes role towards the ceiling as he absentmindedly interrupts the inferior voice on the other side of the line.

He blows his stack often.  In fact, so often that his staff makes sure his blood pressure pills are awaiting at his desk every morning.  He has had a heart attack, or angioplasty, or CABG.  Even though he has survived his own health catastrophe, he still asks the drug reps to bring greasy fried food.

He remembers a time when during residency his attending put a cigarette out on a ventilator while discussing a patient.  Maybe, he even did it himself.

He is a curmudgeon.  He is a relic.

It is easy for today's society to turn our heads embarrassingly away from such a caricature.  Yet for decades his patients swore by his accuracy and skill.  His rough exterior melted away when confronted with a sickly grandparent, or holding the hand of a grieving family member.

He is a man of contradictions.  He is a dying breed.

Take a close look if you will.  Whether you think he is a work of art, or a reflection of our jaded history is totally irrelevant

His day has passed

Sofia Was A Win

Sofia was a win.  She came to my office because she felt that her previous doctor was not careful enough.  And indeed, upon perusing her past medical records, I noticed a blip on her cat scan that he had failed to follow up.  Months later after surgery and chemotherapy, she returned with a broad smile on her face.  The oncologist and surgeon told her that I saved her life.  They explained that the only reason she survived this cancer was because of such early detection.

I basked in the glow of Sofia's success.  As physicians, we face death and destruction on a daily basis.  It feels quite gratifying when outcomes are better than expected.  Over the years, and many visits, we formed a bond based on trust and familiarity.  We struggled with some issues, and sailed through others.

It would have never occurred to me to describe Sofia as anything other than a highly satisfied patient.  So when I decided to change practices and physically move twenty five minutes north, I had no doubt that she would follow me.  After all, I had one hundred year olds willing to hobble along on their walkers to make the extra trip.

I remember the last time I saw Sofia in the office.  She took my new business card and told me that she would call in a  few months.  She never did.  Eventually, realizing her absence, I left a message on her voice mail.  Several calls later, her husband picked up and explained that the twenty five minute drive was too far.  She would rather see one of my old partners at my previous location.  I was stunned.

There are dark times in medicine.  Times when I sit in my office long after all the patients and staff have left.  Alone at my desk in the solitude, I occasionally torture myself with the existential calculus of a life lived in service.  I tabulate the wins and losses in neat but strikingly asymmetric columns.  Everybody dies eventually.

Years later Sofia's face often comes to mind. 

With a pang of sadness it always ceases to be professional,

and becomes overwhelmingly personal.

A Tragedy Based On Administrative Decisions

I gently rotated his arm as the beads of sweat formed on his forehead.  The pain came in waves.  His face contorted and relaxed in repetitive spasms.  I wondered if my exam was in vane.  The cancer had spread from his lungs to his liver and into his bones.  Once the blood stream had been tainted, the aggressive cells took flight and landed in various organ systems. 

We already had the conversation.  I checked the boxes off on the POLST form. 

X Do Not Resuscitate
X Do Not Hospitalize
X No Artifical Nutrition

Yet the hospice team had come and gone, and he refused to sign the papers.  He looked me forcefully in the eyes as he spoke.

You'll take care of it!

But I was starting to feel his confidence was misplaced.  Day after day, I returned to the nursing home to find that our plan was failing to control his late afternoon pain.  Escalating his narcotic dose only provided incremental benefit.  Topical therapy, heat, and message were adding little.

It was only after a week of failed attempts that he pulled me aside and quietly explained his hypothesis.

It's the physical therapy, they're pushing me too hard in physical therapy!

What? I almost fell off my chair. I couldn't help my voice rising in frustration.

Why the heck are you doing physical therapy?

He took a deep breath before answering.  I could tell he was getting tired of my daft intellect.

Because the hospice people told me if I stopped doing physical therapy, I would be dropped from my medicare days and would have to pay my own room and bored.  And then the physical therapy people told me if they don't push me hard enough, I will fail to make enough progress and will also lose my funding.

And like a blind man whose cataracts had just been removed, I once was lost but now could see.  He would live out his last hours struggling through futile physical therapy and in constant pain.  But he would labor selflessly to spare his family the financial burden.  He would expend more of medicare's resources than if he had just been covered under hospice, and would die sooner and in greater pain.

A tragedy based on administrative decisions made by nonclinical staff working for the government.  The pleas of those in the trenches have been ignored.

These silly rules are killing us:

financially and physically.