You Got To Know When to Holdem...Thoughts on Physician Quality

Yesterday my last patient of the day was a young man with a history of multiple surgeries and medical problems. He developed a fever over night to 102 and transient abdominal pain. By the time he saw me his pain was gone but his temperature was still elevated. Knowing this patient as I did, even with the benign exam, I sent him to the ER for a stat cat scan of the abdomen and pelvis and a straight cath (he had urinary retention) for urine. I called the ER Doc to give report before my patient arrived.

From the beginning I was harangued with negative commentary. The Physician shook me down. Why was I sending this patient? The exam was benign why did he need a cat scan. Etc...Etc. By the end of the conversation I simply told the ER Doc...Look, I know this patient..something is wrong. Do the scan!

Two hours later I get a call from the ER. The labs looked OK. He was dehydrated and had a urinary tract infection. His white count wasn't that high. They were going to send him out with antibiotics. So patiently I asked..so what did the scan show?

Of course they hadn't done it. Angrily the ER physician replied, it's going to be negative! Fine we'll do it anyway.

An hour later my cell phone rang. Holy shit....abscess, his temperature is 104. He is going to the operating room now.

And see this is the thing about medicine. Everyone wants to try to measure physician quality using all sorts of strange indicators. Things like blood sugar control, rate of preventative screening exams completed, patient satisfaction. But you see to me...those are all indicators that are highly patient dependent. Either they get them or they don't...often the physician has little to say about it.

In my mind what makes a good physician is a little bit more subtle. In the immortal words of Kenny Rogers:

You got to know when to hold'em, know when to fold'em
Know when to walk away and know when to run!

Snapshots From Childhood-Memories Of My Father

It was too beautiful for words. At least from the perspective of a five year old with greedy eyes and a lustful heart. It was silver, and shiny, and fit perfectly into my little hand.

I watched as my father stood doubtfully at the department store counter. He made a gesture to the attendant and she opened the case and lifted out the object of my adoration. My father took the lighter and held it in his hand. I could see his hand sway gently...getting a feel for the weight of the silver jewel that lay resting quietly in his palm.

He flipped the top of the zippo and it made a wonderful, throaty sound as it opened. Inside a white stranded wick, and a small wheel covering a tiny flint. His thumb fingering the wheel and then giving it a whorl. Sparks flew momentarily and then disappeared.

As my dad looked down at my face he studied my exuberance and then quickly made a decision. He paid the clerk and we exited the store. In the car he opened the lighter. He pulled on the wheel and to my delight he released the inner casing from the shell. He removed the wick, with the caustic smell of lighter fluid emanating from it, and returned the casing. He then handed over the object of my affection.

The lighter was disabled but he left the flint in place. I flicked open the top and fumbled with the wheel. After a few attempts I successfully initiated a spark.

Later that day we drove to summer camp. As I pulled off my seat belt he put his hand out. I fingered the lighter in my pocket and contemplated my next move. I couldn't bare to part with my new found treasure.

He tried one more time...then he warned me. He explained that if he let me keep the zippo I couldn't take it out while at camp. It would surely get taken away. I agreed gratefully and went off to play.

Hours later, my father's warning deeply lost in the recesses of my childhood brain, I pulled out my toy and demonstrated to my friends how to make a spark. Of course I had no idea that the camp counselor was just steps away. She swiftly took the lighter.

I would never see it again.

Years later after my father died I would find a secret stash among his belongings packed in a box.

About a dozen silver zippo lighters...

each beautiful and perfect in its own way....

with flint in place but wick carefully removed

just how he left them.

Why EMR's Are Bad For Helathcare Reform

I was working away in my office yesterday, doing my best to squander our health care dollar, when to my dismay I was hit with a conundrum. The patient in front of me was a young healthy female with right lower quadrant abdominal pain. As I recklessly took a history and examined the patient I formed and incomplete and cost ineffective differential. Her belly was definitely tender. She had a low grade temperature. The list of possibilities danced through my economically unsavy brain. Appendicitis, right sided diverticulitis, kidney stones, gynecologic issues.

Then the answer hit me like a ton of bricks. Gleefully I went to order and expensive cat scan of the abdomen and pelvis. I reached over and picked up the order form and my hand gently moved to the breast pocket of my lab coat. And then it happened...wait for it...wait for it....there was nothing there. I ran, in a quandary, to my desk to find a pen to fill out the form. My desk was picked clean.

And then....then things started to click. My medical assistants and secretaries had been roving the building looking for pens for months now. Slowly but surely they had stripped the doctors office's.

One by one the great pen migration had begun. Months ago. Doctor's in exam rooms and hospitals everywhere had started to feel the pinch. I didn't even flinch the other day when, on my way into the hospital, I was approached by a former friend and colleague. He had a rabid look in his eyes and a uncanny desperation. I quickly brushed him off and assured him that I wasn't hiding any extra pens in my lab coat.

But why...why had the pens in medical facilities become as rare as a primary care doctor who sees his own patients in the hospital?

It was the government. The government had been working for years to curb pharmaceutical influence on our impressionable physician work force and made it illegal for drug companies to use pens as marketing tools. The logic was impenetrable. Ignorant, careless, bonehead physicians were being coaxed to use expensive, harmful pharmaceuticals to the benefit of the industry and the harm of patients everywhere.

The government, however, had no idea how fortuitous this ban could be. Strapped (and cheap) physicians struggling to make ends meet would be very unlikely to replace this free revenue stream by buying more office supplies. As the great pen migration continued physicians would find themselves unable to do the very thing that bureaucrats and reformers have been trying to stop for years. Write new orders!

After all the most expensive technology in medicine is the physicians pen. Now physicians would no longer be able to write for cat scans, mris, and expensive chemotherapy. The health care crises was solved!

And indeed as I struggled to find a writing utensil I did momentarily contemplate skipping the CT Scan and just putting my patient on antibiotics. After all if she actually had appendicitis it would eventually rupture and we would find out soon enough. Right?

But the Obama administration made one fatal error. In its zeal to promote Emr's it forgot that there is one glitch....electronic order entry.

I skipped...nay I ran to the nearest computer. Within minutes I had ordered the cat scan electronically.

Another day...another dollar spent. I guess I could get to like this EMR thing!

Boy....I think I have been reading too much Dr. Rich!

Portraits Of The City (2)

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.

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.

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.

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!