He was fairly odd. Young...in his early twenties. His over sized sweatshirt constrained by a tank top carelessly thrown over. His sweats were just a little too short. Riding up on his legs on each side to reveal black, dry, scaly legs. The colors were unmatching. Gray sweats, a pink sweatshirt, red shirt, no socks, and old beat up white tennis shoes.
His gait was unorthodox. He seem to bounce from step to step. His head bobbing perceptibly up and down and his arms swinging wildly. He shoulders moved side to side with each step.
He had a look of concentration on his face as he entered the playground. It was a rare patch of green amidst the pulsating cityscape. Water tower loomed gently over our heads. The chirping of the birds intermixed with the episodic screeches of a dozen kids. Climbing on jungle gyms, sliding down slides, chasing after each other.
Although the kids barely noticed the new visitor the adults on the playground became rigid. Cautiously they herded their children away towards perceived safety. Cameron and Leila instinctively moved closer as I loitered toward the edge behind the swings.
He walked within ten feet of me and planted himself on the jungle gym. He cast his arms out wildly and began to move in a somewhat familiar manner. He was stretching. Using the wayward structure to twist his body in unorthodox ways. Nothing like the stretching I had done in my workout days.
He continued for a few minutes to carry out a number of bizarre exercises that bore little resemblance to the push ups, sit ups, and dips of my youth. And then he sat for a moment. He looked up towards me with an innocent grin and our eyes met as my head nodded gently.
Then he sprang towards the exit and tottered out. The parents slowly migrated back with their kids in tow. Before long the playground erupted in the joyous rapture of childhood noise.
And I sat as if in a trance. Never quite feeling fear, I was more saddened. He was harmless. Misunderstood. Encumbered by oddity he likely struggled to fit in. So many are born different. Unable to find the human bond with others. Psychologically and physically separated. Like the clothes on his back which failed to match...he failed to blend with society. His pink seemed bizarre when placed next to society's red.
So he ventured out on this beautiful sunny day. Trying to do something adult...like exercise. But he did it is his own way. And he did it in his own place. He had come to the park to be with the children. Not to harm, as some of the parents had thought, but more likely to bond.
After all...in many ways
he probably was one of them.
Tuesday, November 9, 2010
Monday, November 8, 2010
More On Old Fashioned Internal Medicine-Discussing End Of Life Care
I spend a good deal of time talking and thinking about death. It's unavoidable. Not in a morbid or fearful way....more about how to bring my patients dignity and how to bring their families peace. It's something that I do not particularly enjoy...but I am good at it. I have many patients in their eighth and ninth decades, it comes with the territory.
The other day I was lost in thought as I entered the ICU. It was Saturday morning and the hospital was quiet. I was on my way to meet a patient and her four children to discuss whether to continue aggressive medical treatment or opt for comfort care. As I rounded the corner I ran into a surgeon colleague.
I say colleague loosely because we had only worked together once on a single patient. The last time I had seen him was in that very same ICU. Except at that time we were in a conference room, having an end of life discussion with a large family. Around twenty of us. Husband and children, grandchildren and medical professionals. The ICU attending and nursing staff were there. And of course....the surgeon sat quietly next to me.
I cleared my throat and began my talk. First I summarized to the family and staff the patients medical course...using non medical language. Then I described her current prognosis and the different treatment options including aggressive treatment verse comfort care. Lastly I exhorted the family to picture their loved one a year ago. If she could see what was happening to herself now what would she want us to do for her?
Next the surgeon stood up to talk. Although an accomplished pancreatic surgeon known and respected by many....he was gentle and nonintimadating now. He who so deftly maneuvered scalpel and forceps was just as gifted in oratory. Clearly caring and humble...he described what had and hadn't happened right. He layed out the risks and benefits to the family and gave a pause for them to decide.
After many minutes of discussion the family chose comfort care and hospice was called. The patient expired a few hours later.
The surgeon and I convened shortly after the meeting. He was clearly shaken. His grace and easy communication obviously a crutch to hide his inner turmoil. He confided that he had never lost a patient like this before.
As I stumbled upon him again on this quiet Saturday morning I felt a strong emotional connection. It had been pure chance that we had not worked with each other again. He asked about the patients family and how they were doing.
As I think about this encounter it dawns on me that the surgeon really didn't deal with death much. Not the way I do. He hadn't run multiple family meetings each month. He hadn't watched over the years as patients decline with age and are ravaged by chronic disease. He hadn't formed the intellectual and emotional connections with families that only come after years and the roller coaster ride of health and sickness that each of us eventually endures.
And that's what I think Internal Medicine doctors (as well as family practice, palliative care, etc) do well. Especially those that follow during hospitalization. We deal with death...not in abstract terms but in concrete everyday decision making. We are there to guide families at their time of need. This guidance often comes with an intimate knowledge of the patient and family garnered over many years of contact.
I have great fear that as the migration away from Internal Medicine continues we will lose some of this expertise. And it will be our patients....our patients that will suffer the most.
The other day I was lost in thought as I entered the ICU. It was Saturday morning and the hospital was quiet. I was on my way to meet a patient and her four children to discuss whether to continue aggressive medical treatment or opt for comfort care. As I rounded the corner I ran into a surgeon colleague.
I say colleague loosely because we had only worked together once on a single patient. The last time I had seen him was in that very same ICU. Except at that time we were in a conference room, having an end of life discussion with a large family. Around twenty of us. Husband and children, grandchildren and medical professionals. The ICU attending and nursing staff were there. And of course....the surgeon sat quietly next to me.
I cleared my throat and began my talk. First I summarized to the family and staff the patients medical course...using non medical language. Then I described her current prognosis and the different treatment options including aggressive treatment verse comfort care. Lastly I exhorted the family to picture their loved one a year ago. If she could see what was happening to herself now what would she want us to do for her?
Next the surgeon stood up to talk. Although an accomplished pancreatic surgeon known and respected by many....he was gentle and nonintimadating now. He who so deftly maneuvered scalpel and forceps was just as gifted in oratory. Clearly caring and humble...he described what had and hadn't happened right. He layed out the risks and benefits to the family and gave a pause for them to decide.
After many minutes of discussion the family chose comfort care and hospice was called. The patient expired a few hours later.
The surgeon and I convened shortly after the meeting. He was clearly shaken. His grace and easy communication obviously a crutch to hide his inner turmoil. He confided that he had never lost a patient like this before.
As I stumbled upon him again on this quiet Saturday morning I felt a strong emotional connection. It had been pure chance that we had not worked with each other again. He asked about the patients family and how they were doing.
As I think about this encounter it dawns on me that the surgeon really didn't deal with death much. Not the way I do. He hadn't run multiple family meetings each month. He hadn't watched over the years as patients decline with age and are ravaged by chronic disease. He hadn't formed the intellectual and emotional connections with families that only come after years and the roller coaster ride of health and sickness that each of us eventually endures.
And that's what I think Internal Medicine doctors (as well as family practice, palliative care, etc) do well. Especially those that follow during hospitalization. We deal with death...not in abstract terms but in concrete everyday decision making. We are there to guide families at their time of need. This guidance often comes with an intimate knowledge of the patient and family garnered over many years of contact.
I have great fear that as the migration away from Internal Medicine continues we will lose some of this expertise. And it will be our patients....our patients that will suffer the most.
Saturday, November 6, 2010
For Manish
He was my guy. You know...my financial guy. The kind of guy that everybody loves when the market is up. When the market is down....well you know what I'm talking about.
He took me out of pity. The meager sums I saved were nothing near his average client. I was well below his minimum. But we had a common friend. And he liked me....he liked Katie. We were his kind of people. Bargain shoppers. Buy low...sell high. That kind of thing.
Over the years we talked every few months. He would take Katie and I out to dinner before we had kids. Later he would come to the house and entertain Cameron before we could chase our son off to bed and talk financials.
It was a working relationship. But certainly he was the kind of guy I would be friends with anyway. He invited us to his house many times to meet his wife and kids. We always for some reason declined. There was usually something going on. Never enough time.
We eventually learned his story and he ours. About how he met his wife in India. About how he didn't think he would marry and Indian girl. And about his kids and the various activities they were involved in.
It was a relationship. Occasionally it had its turbulence. After all the market was doing horribly. But we still came to him for advice. Sometimes about money. Sometimes about life.
He was kind and considerate. Patient and calm. He always had a smile on his face.
Awhile back he called to tell me he had excepted a job with a new firm. I was proud that instead of expressing dismay or concern about my own financial well being the first thing I said to him was "Congrats...I'm happy for you!" He was surprised. I was the only client who had congratulated him. Later we talked about how we would move our funds over to his new firm. I could care less who he worked for...it was his advice I was interested in.
A week later I called for a brief question about funds transfer. He was in the middle of a meeting but took the time to answer me anyway. Little did I know that those were the last words I would ever speak to him. Thirty minutes later he collapsed in his office. In a few days he was gone. He never woke up.
Katie and I went to his funeral. As I watched his wife and children I flashed back to my own father's death. He died the same way. As I approached the casket I mumbled condolences to his family. And there he was. His face edematous and puffy. Unrecognizable compared to the handsome smiling face imprinted on my memory.
During the ceremony family and friends spoke about his affect on their lives. His clients were especially vocal. A widow talked of how he had promised to take care of her finances after her husband's death. And he had. An older man spoke of how he had traveled with him to India to guide him in search of his parents ancestry and to spread their ashes. He called him his son. There was no blood relation.
Then there was me. The fool that I was...I had thought that this gentle human being was brought into my life to teach me about money. Money! Useless money!
In reality his lessons were much more valuable. Comapssion...Joy...love. All things he gently taught, quietly, in his humble way...by example.
And his distorted face and body lying in the casket. Not a true window into his soul but more an unkind reflection of what I had become.
One last lesson taught by a masterful teacher....
I wonder If I deserve as much.
He took me out of pity. The meager sums I saved were nothing near his average client. I was well below his minimum. But we had a common friend. And he liked me....he liked Katie. We were his kind of people. Bargain shoppers. Buy low...sell high. That kind of thing.
Over the years we talked every few months. He would take Katie and I out to dinner before we had kids. Later he would come to the house and entertain Cameron before we could chase our son off to bed and talk financials.
It was a working relationship. But certainly he was the kind of guy I would be friends with anyway. He invited us to his house many times to meet his wife and kids. We always for some reason declined. There was usually something going on. Never enough time.
We eventually learned his story and he ours. About how he met his wife in India. About how he didn't think he would marry and Indian girl. And about his kids and the various activities they were involved in.
It was a relationship. Occasionally it had its turbulence. After all the market was doing horribly. But we still came to him for advice. Sometimes about money. Sometimes about life.
He was kind and considerate. Patient and calm. He always had a smile on his face.
Awhile back he called to tell me he had excepted a job with a new firm. I was proud that instead of expressing dismay or concern about my own financial well being the first thing I said to him was "Congrats...I'm happy for you!" He was surprised. I was the only client who had congratulated him. Later we talked about how we would move our funds over to his new firm. I could care less who he worked for...it was his advice I was interested in.
A week later I called for a brief question about funds transfer. He was in the middle of a meeting but took the time to answer me anyway. Little did I know that those were the last words I would ever speak to him. Thirty minutes later he collapsed in his office. In a few days he was gone. He never woke up.
Katie and I went to his funeral. As I watched his wife and children I flashed back to my own father's death. He died the same way. As I approached the casket I mumbled condolences to his family. And there he was. His face edematous and puffy. Unrecognizable compared to the handsome smiling face imprinted on my memory.
During the ceremony family and friends spoke about his affect on their lives. His clients were especially vocal. A widow talked of how he had promised to take care of her finances after her husband's death. And he had. An older man spoke of how he had traveled with him to India to guide him in search of his parents ancestry and to spread their ashes. He called him his son. There was no blood relation.
Then there was me. The fool that I was...I had thought that this gentle human being was brought into my life to teach me about money. Money! Useless money!
In reality his lessons were much more valuable. Comapssion...Joy...love. All things he gently taught, quietly, in his humble way...by example.
And his distorted face and body lying in the casket. Not a true window into his soul but more an unkind reflection of what I had become.
One last lesson taught by a masterful teacher....
I wonder If I deserve as much.
Friday, November 5, 2010
Internal Medicine-Waiting For Godot?
She was like....Superwoman. A strapping medical visionary probably in her forties. Gray long coat falling below the knees. She strode confidently down the hallway towards the elevator, a father hurrying beside her with his young lanky daughter cradled in his arms. The girl's head nuzzled into her father's shoulder. She was old enough to walk by herself...but clearly she was sick. Unable.
Undoubtedly they were headed from the medical complex to the ER which was a few hundred feet away. As I walked past them towards my own office door one clear thought leaped into mind. Boy....I wish I was a doctor. Then I froze. Wait...I am...I am a doctor. But maybe I no longer feel like that kind of Doctor. You know, the one with a capital D. As in MD. The one who throws caution to the wind and runs out of a full office of patients to escort an ailing person and family member to the ER. The one who rushes out of a crowd to perform CPR on the elderly lady who collapses in the shopping mall.
Unfortunately most of us in Internal Medicine have found our jobs and lives deranged to the extent that we no longer feel the strength and surge of emotion that brought us into the profession in the first place. Most of us have lost our inner Superman. And our patients have grown tired of waiting.
It's been going on for years now. The devaluation of primary care and especially Internal Medicine. It started with the loss of technical abilities. Over the years Internists have given up most of the manual labor. We no longer perform biopsies, place central lines, lumbar punctures, or manage ventilators. We have ceded these skills to specialists.
This loss of technical prowess has had far reaching implications. For one...our patients, as well as our specialist colleagues, no longer see us as doers....they only see us as thinkers.
And this by itself is no big deal. If you need your car fixed you go to a mechanic. And we don't want to be mechanics. So we embrace our new vision as thinkers. We are warm, kind physicians, who a patient can talk to. We use manual dexterity through physical exam and pure wit to solve medical problems.
Except....that over the years physical exam has been undervalued. Medical training has moved to lab and radiology based evaluations. The Internist no longer prides himself on exam skills. Who needs to know the ins and outs of heart murmurs when you are going to order an echo anyway.
So Internal Medicine lost its concentration on manual dexterity...and turned towards mental gymnastics. I am reminded of Rodin's Thinking Man sculpture. We are now the astronomers and philosophers. Physicists and scientists. We can live with that!
Now take the Thinking Man and remove hand from chin and place squarely on mouse. Take other hand from knee and fill with preprinted checklists and practice guidelines. Tell Thinking Man he has 7.5 minutes till his next patient appears and he will have to strike the same pose in the next exam room with a new patient.
What you get is a thoughtless, hurried physician, who feels impotent. He is isolated from his patients emotionally. He is boxed in by a computer that doesn't allow eye contact. He is isolated physically by a loss of manual dexterity and an overwhelmingly belief by both patient and physician that tests are more important than human touch. And lastly he is isolated mentally by rules and regulations, check lists, and inadequate time to fulfill his role as a thinking man.
Our patients are figuring this out. They are leaving our practices and going to minute clinics, specialists, emergency rooms, and alternative medicine practitioners. They are taking on cute names and becoming epatients and creating their own empowerment movement.
They are sick and tired and frustrated by us supposed supermen who are enslaved in straight jackets of cryptonite. They have been here before.
Our patients know what happens when you're waiting for Godot....
You sit around an awful long time....
But ultimately...ultimately..
no one comes!
Undoubtedly they were headed from the medical complex to the ER which was a few hundred feet away. As I walked past them towards my own office door one clear thought leaped into mind. Boy....I wish I was a doctor. Then I froze. Wait...I am...I am a doctor. But maybe I no longer feel like that kind of Doctor. You know, the one with a capital D. As in MD. The one who throws caution to the wind and runs out of a full office of patients to escort an ailing person and family member to the ER. The one who rushes out of a crowd to perform CPR on the elderly lady who collapses in the shopping mall.
Unfortunately most of us in Internal Medicine have found our jobs and lives deranged to the extent that we no longer feel the strength and surge of emotion that brought us into the profession in the first place. Most of us have lost our inner Superman. And our patients have grown tired of waiting.
It's been going on for years now. The devaluation of primary care and especially Internal Medicine. It started with the loss of technical abilities. Over the years Internists have given up most of the manual labor. We no longer perform biopsies, place central lines, lumbar punctures, or manage ventilators. We have ceded these skills to specialists.
This loss of technical prowess has had far reaching implications. For one...our patients, as well as our specialist colleagues, no longer see us as doers....they only see us as thinkers.
And this by itself is no big deal. If you need your car fixed you go to a mechanic. And we don't want to be mechanics. So we embrace our new vision as thinkers. We are warm, kind physicians, who a patient can talk to. We use manual dexterity through physical exam and pure wit to solve medical problems.
Except....that over the years physical exam has been undervalued. Medical training has moved to lab and radiology based evaluations. The Internist no longer prides himself on exam skills. Who needs to know the ins and outs of heart murmurs when you are going to order an echo anyway.
So Internal Medicine lost its concentration on manual dexterity...and turned towards mental gymnastics. I am reminded of Rodin's Thinking Man sculpture. We are now the astronomers and philosophers. Physicists and scientists. We can live with that!
Now take the Thinking Man and remove hand from chin and place squarely on mouse. Take other hand from knee and fill with preprinted checklists and practice guidelines. Tell Thinking Man he has 7.5 minutes till his next patient appears and he will have to strike the same pose in the next exam room with a new patient.
What you get is a thoughtless, hurried physician, who feels impotent. He is isolated from his patients emotionally. He is boxed in by a computer that doesn't allow eye contact. He is isolated physically by a loss of manual dexterity and an overwhelmingly belief by both patient and physician that tests are more important than human touch. And lastly he is isolated mentally by rules and regulations, check lists, and inadequate time to fulfill his role as a thinking man.
Our patients are figuring this out. They are leaving our practices and going to minute clinics, specialists, emergency rooms, and alternative medicine practitioners. They are taking on cute names and becoming epatients and creating their own empowerment movement.
They are sick and tired and frustrated by us supposed supermen who are enslaved in straight jackets of cryptonite. They have been here before.
Our patients know what happens when you're waiting for Godot....
You sit around an awful long time....
But ultimately...ultimately..
no one comes!
Thursday, November 4, 2010
Portraits of the CIty
Head down.
Feet forward.
Hands Up.
On Michigan Ave.
Where the rich people shop.
Hat in the air.
Catchin quarters.
Head down.
Feet Forward.
Hands Up.
Squattin like a boy.
Curled in a ball
To escape the blows.
Of his father.
Head down.
Feet Forward.
Hands Up.
Watchin shoes.
The more beat up
The more they leave.
Head down.
Feet Forward.
Hands up.
Makin a few bucks.
For the long...cold
winter.
Feet forward.
Hands Up.
On Michigan Ave.
Where the rich people shop.
Hat in the air.
Catchin quarters.
Head down.
Feet Forward.
Hands Up.
Squattin like a boy.
Curled in a ball
To escape the blows.
Of his father.
Head down.
Feet Forward.
Hands Up.
Watchin shoes.
The more beat up
The more they leave.
Head down.
Feet Forward.
Hands up.
Makin a few bucks.
For the long...cold
winter.
Wednesday, November 3, 2010
In Memorium-Snap Shots
My son is standing in the Principal's office. Or actually it's not my son...it's me. That's just how I picture myself in my minds eye when I think back to when I was his age. I am struggling with a large winter coat. I lay it on the floor upside down. Thrust my arms into the sleeves and flip it over my head. I pull on my hat. At first covering my eyes and then giggling...push it back upward.
It's the middle of the school day. While I am aware that it is highly unusual for the teacher to have taken me out of class and told me to bring my coat, my young mind has not yet been poisoned by fear of the unexpected.
The Principal's office is drab. Old stained linoleum on the floor and off gray popcorn ceiling. I have a pair of gloves which are tied together by a string and looped through my coat sleeves. I pull them on and hop around the room on one foot making monkey sounds. The secretary raises an eyebrow but remains quiet.
I am expecting my mom to come through the door at any moment but instead her best friend enters briskly. She barely notices me and walks to the secretary's desk. The secretary nods gently in my direction. The friend walks over and grabs my hand....come on honey, we have to go.
I agree willingly but now even in my seven year old brain I know something is wrong.
As we walk out the front door of the school the wind hits my face. It's a cold winter day and I have to concentrate on the steps to avoid slipping on the ice. I stop and look up into my mom's friends face. Where's my mom?
She pauses, takes a deep breath, and then responds coldly...at the hospital. Then a single tear drops down from her eye onto her cheek. Only my adult mind understands the look of pity on her face as she prepares to tell me, a little boy, that my life will never be the same.
Something has happened to your father.
It's the middle of the school day. While I am aware that it is highly unusual for the teacher to have taken me out of class and told me to bring my coat, my young mind has not yet been poisoned by fear of the unexpected.
The Principal's office is drab. Old stained linoleum on the floor and off gray popcorn ceiling. I have a pair of gloves which are tied together by a string and looped through my coat sleeves. I pull them on and hop around the room on one foot making monkey sounds. The secretary raises an eyebrow but remains quiet.
I am expecting my mom to come through the door at any moment but instead her best friend enters briskly. She barely notices me and walks to the secretary's desk. The secretary nods gently in my direction. The friend walks over and grabs my hand....come on honey, we have to go.
I agree willingly but now even in my seven year old brain I know something is wrong.
As we walk out the front door of the school the wind hits my face. It's a cold winter day and I have to concentrate on the steps to avoid slipping on the ice. I stop and look up into my mom's friends face. Where's my mom?
She pauses, takes a deep breath, and then responds coldly...at the hospital. Then a single tear drops down from her eye onto her cheek. Only my adult mind understands the look of pity on her face as she prepares to tell me, a little boy, that my life will never be the same.
Something has happened to your father.
Tuesday, January 12, 2010
I Wish They Would Just Leave Me Alone
I wish I knew how to express myself. I wish I knew how to put this into words. How the direction of things has just become depressing. How each day makes me wonder how we got to where we are today. And I think back. Back to the beginning.
I think back to my childhood. And how I looked up to my father...the physician. How he died when I was so young. His last gift to me was his profession. How an eight year old somehow made a decision about what he would do with his life. It didn't matter that I had a learning disability.
My thoughts were pure. My intentions the best. Money was the farthest thing from my mind. I studied hard. Tackling the first years of medical school with vigor. Scoring among the highest in my class. Only to be whacked by the reality of my clinicals. Abused by some of my teachers, undercut by fellow students.
I entered residency a little less naive but no less excited. I married. I matured. I held my patients well being in my hands as best as I could. The weight of responsibility sometimes crushed me. There was that night in the ICU when the elderly man in respiratory distress crashed. Where I botched the code. And then had to tell his family over the phone. And the guilt ate my insides out. And I clammed up. The night I dropped my applications to fellowship.
I became cold...but no less dedicated. I lost my self in a protectionalist shell. I replaced joy with calm. I replaced tenderness with cold clinical aassessments. And I became the doctor that I despised. Maybe not to my patients or to my colleagues but I knew the difference. I felt so much rage against the system...against the medical group that I worked for....against the government who wouldn't let me practice the way I wanted to....and sometimes against the patients themselves.
But then my first child was born. And I started to blog. And my heart opened up. I learned how to feel with my patients. How to cry with them. I took their stories home with me each night. And my skills grew. I learned how to read into not only what a patient said but how they said things. I watched the way they walked into the exam room. The way they held their head.
I became a better physician. I learned how to help my patients live with disease....I helped them learn how to die with dignity. I started to catch things that others didn't. Things I had only read about...the guy who was traveling and got erhlichia, the lupus patient with csf rhinorhea who got methemoglobinemia from dapsone,the diffuse lewy body disease missed by the neurologist, the conns syndrome, and the young guy with acromegaly.
And I learned how to be economically as well as medically efficient. Only consulting specialists when absolutely necessary, eschewing antibiotics for watchful waiting, managing patients in the office or nursing home when my colleagues would have put them in the hospital, billing the same yearly totals as my piers but seeing hundreds more patients in the same time period.
I make a nice living. Much better then I ever thought I would. My office is full. The nursing homes are always calling. I see my own patients in the hospital. I am efficient but thorough. I may only spend 10 minutes in the room with the ninety year old with chf,diabetes,and copd. but I also spend 10 minutes reviewing her chart. And 15 minutes on two separate occasions with her on the phone. And 30 minutes calling her cardiologist discussing my plan for her.
But things are changing in medicine. Overwhelmed by a system that costs too much the government is forced to make changes. And the debate roles on about who is at fault. Is it the insurance industry...pharma.....or doctors. We all know that the doctors pen is the most expensive technology in health care.
We all say that primary care doctors are not paid enough. But in the same breath we say that they inefficiently manage their patients, order to many tests, consult too many specialists, and miss to many diagnosis. We talk about quality as if it is something that anyone really knows how to measure.
And I see such change coming. Medical homes...pay for performance....bundled payments....employed physicians.....the endless jargon of health care reform. And my anxiety grows. For those who practice ineffectively some of these government intrusions will undoubtedly bring them in line. But for some of us....those who have prided themselves on cost effective, efficient care...these changes will just slow us down. They will make it harder to get reimbursed at our current level. They will produce more silly administrative hoops to jump through. More useless pain. Eventually many of us will leave. Why not work for an insurance or drug company. Even if we are happier practicing...at least our type of medicine.
It makes me sad. And makes me think....the reformers...the government....I wish they would just leave me alone.
I think back to my childhood. And how I looked up to my father...the physician. How he died when I was so young. His last gift to me was his profession. How an eight year old somehow made a decision about what he would do with his life. It didn't matter that I had a learning disability.
My thoughts were pure. My intentions the best. Money was the farthest thing from my mind. I studied hard. Tackling the first years of medical school with vigor. Scoring among the highest in my class. Only to be whacked by the reality of my clinicals. Abused by some of my teachers, undercut by fellow students.
I entered residency a little less naive but no less excited. I married. I matured. I held my patients well being in my hands as best as I could. The weight of responsibility sometimes crushed me. There was that night in the ICU when the elderly man in respiratory distress crashed. Where I botched the code. And then had to tell his family over the phone. And the guilt ate my insides out. And I clammed up. The night I dropped my applications to fellowship.
I became cold...but no less dedicated. I lost my self in a protectionalist shell. I replaced joy with calm. I replaced tenderness with cold clinical aassessments. And I became the doctor that I despised. Maybe not to my patients or to my colleagues but I knew the difference. I felt so much rage against the system...against the medical group that I worked for....against the government who wouldn't let me practice the way I wanted to....and sometimes against the patients themselves.
But then my first child was born. And I started to blog. And my heart opened up. I learned how to feel with my patients. How to cry with them. I took their stories home with me each night. And my skills grew. I learned how to read into not only what a patient said but how they said things. I watched the way they walked into the exam room. The way they held their head.
I became a better physician. I learned how to help my patients live with disease....I helped them learn how to die with dignity. I started to catch things that others didn't. Things I had only read about...the guy who was traveling and got erhlichia, the lupus patient with csf rhinorhea who got methemoglobinemia from dapsone,the diffuse lewy body disease missed by the neurologist, the conns syndrome, and the young guy with acromegaly.
And I learned how to be economically as well as medically efficient. Only consulting specialists when absolutely necessary, eschewing antibiotics for watchful waiting, managing patients in the office or nursing home when my colleagues would have put them in the hospital, billing the same yearly totals as my piers but seeing hundreds more patients in the same time period.
I make a nice living. Much better then I ever thought I would. My office is full. The nursing homes are always calling. I see my own patients in the hospital. I am efficient but thorough. I may only spend 10 minutes in the room with the ninety year old with chf,diabetes,and copd. but I also spend 10 minutes reviewing her chart. And 15 minutes on two separate occasions with her on the phone. And 30 minutes calling her cardiologist discussing my plan for her.
But things are changing in medicine. Overwhelmed by a system that costs too much the government is forced to make changes. And the debate roles on about who is at fault. Is it the insurance industry...pharma.....or doctors. We all know that the doctors pen is the most expensive technology in health care.
We all say that primary care doctors are not paid enough. But in the same breath we say that they inefficiently manage their patients, order to many tests, consult too many specialists, and miss to many diagnosis. We talk about quality as if it is something that anyone really knows how to measure.
And I see such change coming. Medical homes...pay for performance....bundled payments....employed physicians.....the endless jargon of health care reform. And my anxiety grows. For those who practice ineffectively some of these government intrusions will undoubtedly bring them in line. But for some of us....those who have prided themselves on cost effective, efficient care...these changes will just slow us down. They will make it harder to get reimbursed at our current level. They will produce more silly administrative hoops to jump through. More useless pain. Eventually many of us will leave. Why not work for an insurance or drug company. Even if we are happier practicing...at least our type of medicine.
It makes me sad. And makes me think....the reformers...the government....I wish they would just leave me alone.
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