What's Been Left Out

Would You Do It Again?

Over on my other blog, every Monday, I write Good Decision/Bad Decision posts.  The idea is to dissect a decision, usually financial, from various viewpoints.  Nothing we do in life is truly good or bad, there are always consequences.  This week, I am going to tackle something a little more personal.  Should I have gone to medical school?

This question is fraught with emotional pitfalls.  How could it not be?  From the moment I can remember, I have wanted to be a doctor.  It has been with me for every breath and aspiration.  Now at the age of 44, Almost twenty years into my career, I can't help but look back and wonder.  Was it all worth it?

What's Been Left Out

I love being a doctor.  There are so many insights that I have gained by being on the edge of life and death with my patients.  The privilege is such, that even my aptitude for verbosity, only manages to scratch the surface.  I live a charmed life.  I have been lucky.

But.

Remember that when someone follows a statement with the word but, it means to forget every idea that came directly before.

But, this profession has cost me dearly.

It has cost time and money, strength and energy, character and innocence.  I am not the man I once was.  Not the man I would be if I chose business or law as my profession.  There are many roads in life, who knows who we would have become if we chose the path not taken.

I know This Much

Medicine has hurt me.  It has ruined my body and mind.  I wake upon every morning fifteen years after residency with a shattered sleeping pattern.  I go about my day immune to the everyday suffering of those around me.

You think... is bad.  You should see the young guy I am taking care of with pancreatic cancer.

I am impatient.  Very impatient.  Trained from years of arguing, demanding, and doing whatever it takes in minute allotments of time, I can barely wait in the grocery line without bursting into flames.

And I am cold.  So cold.  Frigid.  Wrapped in the blanket of ice of self protectionism.  Surrounded by walls built and shattered so many times that there strength has doubled from scarring.

You only have to feel responsible for one death.  Only have to watch the tears of one family for a few minutes.  Then try that a hundred times.  Maybe more.  Unlikely less.

Undone

We can't undo our decisions.  I cannot just stop being a doctor.  The practice of medicine is what I do,  but quitting cannot unmake who I am or what I have endured.

Medicine is a privilege.  The ultimate privilege.

But it comes with an unbearable cost.

How the hell do I know if I would pay it again?

Isn't It Ironic, Don't You think?

I Hate EMR's

There.  I said it.  The bane of my existence, as a primary care physician, are the idiotic electronic medical records I have been forced to use.  Lets see...I have mastered Epic, Point Click Care, All scripts, Practice Fusion, etc., etc.  I can't even begin to remember all the different systems.  

The one point that is glaringly clear, they have added pain, frustration, and increasing amounts of time.  But none, I said none, have actually improved patient care.  I have spent thousands of dollars and countless hours using electronic medical records.  They have altered my work flow, disturbed my connection with my patients, and otherwise consumed more time than actual patient evaluations.  

In case I haven't said it before on this blog, EMR's were one of the main reasons I decided to leave my traditional primary care office and start a a home based concierge practice.  Even if I still had to participate in the folly of governmental mandates, I at least had more time to count my clicks and argue with my patients over signing up for the patient portal.  

Meaningful Use, MACRA

I have fully complied with meaningful use and MACRA.  I have received bonuses over the years.  These payments were made on the back of my poor patients who had to suffer through the pointing and clicking.  

I finally gave up.  I stopped seeing outpatients this January and now do nursing home and hospice work only.  I chart on the medical record in the nursing home which is owned by the facility,  and thus I cannot submit any data.  Medicare doesn't recognize the difficulty of this situation.  Starting in 2020 they will cut my payments until they whittle off 10%.  To start with.

The truth is, I really don't give a flying #$#@.  As I have documented elsewhere, I no longer practice to make a living anyway.  I have that covered.  So if Medicare wants to cut my payments, so be it.  

Have at it Medicare.  I give up.

The Last Laugh

Since I was still seeing patients in 2017 and charting on my own EMR, I decided to try to comply with MACRA.   I could submit at least one piece of data so that I could maintain current payment levels in 2019 for my nursing home billings.  For the first year of MACRA, the bar is quite low.  

My personal assistant convinced me to send in a whole 3 months of data.

Just in case, you never know.

I got a letter today from the EMR company.  Apparently my data was good.  Great even.  I am going to get a 4% bonus above the baseline for 2019.  This is more than I expected.  I was just hoping not to be cut.  

It's irony, isn't it?  When I was working hard to meet the governments needs, I was barely getting by.  

Now I have decided to give them the middle finger.

And I'm getting a 4% bonus. 

That Which I Miss Most

Empathy

My eyes glare across the table.  I can feel his shoulders hunch forward as he subconsciously recoils in preparation for my response.  The room becomes thick.  Nurses, social workers, a chaplain.  Everyone waiting for the doctor.

Not just the doctor, but me.  Sixteen years out of residency.  Battle scarred and warn by PTSD.  The images from residency still so clear.  A gasp, a gurgle, flat line.  Wailing family members, angry nurses, and an uncompromising chief.  

They died so much more easily back then.  The young, the old, the unwanted, and the uncared for.  The academic medical center with it's social mission.  The Veterans Administration with it's untethered and unloved.  

Practice.  We practiced for lack of a better word.  We  stumbled into situations too big and too great for our burgeoning grip on competence.  We learned as we taught.  We taught as we mastered.  We mastered in the single digits. 

Battle Worn

Emerging from training was like a breath of air.  But not clean air.  Smog.  The same thickness.  Life's murkiness banished to that protected oasis long hidden in the recesses.  Just out of reach.  

Schedules fill.  Patients to squeeze in.  The morass of physical and emotional trauma.  Ducking from the base insults hurled at our backs, and delivering the same into the next examining room when patience grows thin.  

Dragging such toxicity home on the belabored backs of our families.  Of our children.  The raspy voice declares death over the phone with cold and surgical certainty while the kids watch cartoons on a Sunday morning.  Clear eyed retribution turns to tears when the story line on the big screen goes awry.  

That Which I Miss Most.  

In this beloved room full of colleagues battling to make the last gasps of life bearable.  Is the softness.  The weakness of heart and the quietness of spirit.  The empathy that lifted those around me instead of made them cower.  

The absence of fear, and anger, and helplessness.

Not of battling life or death.  Not of winning or losing.  But of learning to feel unhindered.  To feel again.

I defang my claws.  Drop my shoulders and consciously restrain the edge in my voice.

And I do my best to fake it.

     

Something Different

And the dam breaks  

Because it always does.  As the rebellious seas churn and the indelible cracks breach at the base, a web of infirmity spreads it's lacey tendrils unloosening the mooring of a once sturdy structure.  The cackling of unhinged cement, the prepubescent rejoinder to the whoosh as the frothy waters churn past what once was solid, absolving the absurdity of insincere firmness.  That which was an obstacle, now a conduit.  

The mark of the trainee.  The years of suffering, and sweating, and staring down disaster with a stiff upper lip and trembling twenty-four hour knees.  The abuse.  Rampant abuse.  From patients.  From colleagues. From the dumb luck of being on the opposite side of death.  A familiar foe with unbearable strength and agility.

The self effacement.  The drowning of ones own needs.  The rumpled collar, greasy hair, and lazy eyes of a night on call.  Sleep abandoned.  Needs betrayed.  Humanity unraveled into a dream laden schedule.  Every few days.

A calling.  A calling to duty.  A call to sacrifice.

And the dam breaks

Because it had to.  Patients replaced by computers.  Insurance forms and boxes to check, and minutia upon minutia.  Upon minutia.  Until the little becomes so big that you become little too.  With tiny pitiable goals and aspirations.

Far from a healer.  You are a generator of paper.  A signer of forms.  A whipping boy for an ungodly mechanical voice heard disjointedly from somewhere up above.

That drug is not formulary!
That admission is an observation!
That is not a C3, it's a C2!  Run to the fax machine.

Suggestions become commands.  Commands become dictates.  Dictates become laws.

Laws we abide while sneering.  Pitiful sneers that make us hide from the reflection in the mirror.  The reflection in the eyes of those we had sworn to serve.

I'm sorry you're having the most shitty day of your life.  But I can't seem to remember how to order that  coffin in my electronic medical record.  What's the ICD-10 for death?

And the dam breaks

Because the words stop coming.  There is simply nothing more to be said.  There are only so many eloquent ways to talk about something that is broken.  Smashed to pieces.  The whole no longer exists.  



 

Swindled

You've been swindled.  At least that's the conclusion I've come to.  It wasn't the hucksters or the snake oil salesman.  It wasn't big business, big medicine, or some greedy hospital administrator.  It was most likely pharma with a large dose of helping from your doctor.  Plain and simple.

I've learned quite a bit being a hospice medical director.  Covering dozens of new admissions a week has given me much insight into doctor prescribing habits.  Often it is my job to decide with meds are necessary and covered by hospice, which are necessary but not covered by hospice, and which are useless.

Do you have any idea how many useless and often harmful meds our patients are on? I'm not just talking about end of life, but healthy patients to.

Can we talk multivitamins?  Almost every patient I encounter is prescribed a multivitamin.  Healthy, unhealthy, living, dying.  When your in the grasps of stage five thousand and one lung cancer and your brain is riddled with mets, you have no business being on a multi.  It's not going to help you.  It's not going to provide that last bit of energy to overcome the calamitous collapse that is approaching rapidly.  In fact, there is plenty of data to suggest multivitamins are harmful if not neutral at best.  Even in healthy people.

How about Vitamin D?  I swear to g-d, every patient I encounter is on some sort of D supplement.  Never mind that the vast majority of medical evidence implies that supplementation is unhelpful in most disease processes.  Yes, there is osteoporosis, but otherwise, it is a non starter.

Aricept in patients who don't walk, don't talk, and barely interact with the world around them?  Again, started often because there is no other treatment, profound dementia patients are submitted to a host of side effects including diarrhea and syncope without the faintest glimpse of medical benefit.

Vitamin C, Vitamin E, Calcium?

How about statins in patients without a history of coronary disease with end stage-opathies  and malignant cancers.  Do we really think we are going to cut down on cardiac events in the fleeting few months that these patients have to live?  Is there any data to support this?  You better believe that these patients get myalgia and other side effects.

Antibiotics for foul smelling urine, screening urine cultures without symptoms, or agitation in an already agitated patient.  It seems that treating non-utis has become the national past time of our healthcare system.

I could go on and on.  Don't even get me started on antibacterials for non bacterial infections.

The point is, we are not being careful with our prescribing habits.  We are not taking into consideration the wealth of evidence and data regarding some of these treatments.

And we are not being good advocates.

We are not shielding our patients from harm.

 

If you want to hear more stories about medicine and personal finance, check out The Earn & Invest Podcast.

And We Must Breathe

Ask any parent.  Having children is a supreme act of faith.  This revelation does not come easy to one who is particularly uncomfortable kneeling at unfamiliar alters.  It hurts my knees.  Yet there is no more durable truism.

It starts with birth.  The awareness of our own unique helplessness is overwhelming.  We are a slave to our children's genetics, environment, and wholly uncontrollable luck.  We skitter to command a million details to defray the constant anxiety of that which can't be governed.  We worry, lose sleep, and panic till the day we feebly shrug our shoulders and accept.  Then we defer to faith.  Because faith is air, and we must breathe.

As my daughter has grown, that faith has transferred from the intangible nebulous, to the burgeoning humanoid sprouting at my feet.  A far more comfortable leap, a sense of control sets in.  As parents, we can lead by example, teach, shape, and mold.  Destiny has temporarily released her grasp.  My daughter can learn not to climb on the hot stove, to look both ways before crossing, to stop, drop, and roll.

So you would think it is the consequential stuff that I struggle with, but often the ephemera nips just as gratingly at my heels.

A few weeks ago, my daughter informed us that she wanted to perform in the annual school talent show.  Each year, we battle to convince her to play the violin, something she actually holds a sprinkling of talent for.  Sometimes we win, others we lose.

This year she decided that she would perform a solo dance routine, and no matter how much I tried, she could not be dissuaded. My anxiety rose as I pondered our weekend dance performances in the family room.  Rhythm, it turns out, may not be at the top of my daughter's otherwise many talents.

Much discussion was had, videos were You Tubed, lists were made.  And two days before the performance, it was clear that her best option was to free style the whole routine.  My heart raced as I pondered her up on that stage in front of hundreds of people, awkward, and embarrassed.  This has been a hard year for her at school, and the last thing I wanted was for it to end in shame.

My daughter, however, was implacable.  She repeated over and over again:

I got this!

The day of the event, she pushed us out of the way and applied her own makeup.  I marveled at the mix of eye liner and lipstick (something we otherwise would never let our daughter wear).  She looked fierce.

When she took the stage at the tail end of the show after fifty other acts, I stood nervously with camera in hand.  She awaited patiently through three attempts to queue her music correctly.  I could no longer control the fluttering in my chest.

I keenly felt at that moment something, in retrospect, I have always known.  

That I will follow this girl with all my heart down whichever path she leads.  And I will have faith even though the journey will often be awkward and painful and sometimes...

Sometimes joyful and wondrous.

Changing Lanes

I drive a fast car.  Which if you know me, is quite uncharacteristic.  I would say that it is one the few possessions that generally doesn't reflect upon who I am.  How I chose this car, the make, and model, are a long story not to be discussed here.  But let's just say that it has quite a kick.

These thoughts jostled through my mind this morning as I pulled into the hospital parking lot.   A recent momentous decision, I surrendered my privileges at this hospital and started using the hospitalists.  It had all become too hard.  The inane compliance issues with the new EMR.  The ER attendings admitting my patients without calling me.  The slew of protocols, documents, and attestations at this institution recently became particularly onerous. The administration was pushing out the primary physicians with the indignation of a million not so subtle pinpricks.

I was making a courtesy visit.  I had asked the Emergency Room physician to have the hospitalist call me the night before.  I knew this patient exceedingly well over the years, and had a good impression of what had happened.  I was unable to relay this information, however, because I never got a phone call.

I didn't agree with the diagnosis or treatment plan.  The admitting hospitalist was no longer available and the nursing staff had no idea who to call.  I carefully documented my knowledge of the patients past medical history, exam, and my thoughts in a progress note.  I also left my mobile number and begged the rounding physician to call me.  I am not hopeful.  Eventually, after much searching and paging, I will likely reach the physician by the end of the day.  Que sera, sera.

This hospital is in the midst of a major rebuild, and part of the process is a new entrance to the expressway adjacent to the parking lot.  The beauty of this new pathway is that following a few careening turns, the entrance ramp is a straight shot for a few hundred feet.

This morning, I came to a full stop after those turns, and waited for the cars on the expressway to pass at 60 mph.  I put all four windows down.  Then I put the pedal to the metal.

10, 30, 50, 70mph,  I sped past all the cars ahead of me.  The wind blowing into the car and smacking me in the face.  Power, speed, freedom, joy!

Eventually I merged left and began the process of applying the brakes.  I was coming up quickly on a series of cars driving at more conventional speeds.

The fun is over.  It couldn't last forever.

It seems it's no longer our patients that we answer to.

Because I've been told, in no uncertain terms, it's time to stop bucking the system.

And get back into my appointed lane.