Ah,,,,The Holidays

Something happens the last three months of the year. Every year. It's like clockwork....our lives go haywire. Instead of happiness the holidays bring pain and suffering, malevolence and discontent, and oh ya.....plain old anger. It's a frustrating time to be a physician.

The old people die.

Every year during the holidays. In droves. Inexplicably. Out of nowhere. One or two a week. Sometimes after long periods of suffering. Sometimes, all of the sudden, to every one's surprise. In greater numbers then in all the other months of the year.

The middle aged and chronically ill get depressed.

Highly functioning people become psychotic. As if something threw them over the edge or under the bus. Mental status change is the complaint of the day until it is dethroned by inexplicable pain. All over the body. Immune to the foraging fingers of cat scans and mri's. Resistant to even the most obscure blood tests. Antidepressants are dispensed like life saving oxygen.

The young get mad.

Mad that they feel unease. Mad at our busy schedules. Mad that illness is a resistant and often obnoxious foe that doesn't always bend to the will of the hapless physician. So they yell, and scream, and threaten.....as turkeys bake, carollers sing, and snow carpets the land.

And we....the downtrodden and tired. Beleaguered and feeling abused. Bundle up against the cold ice ridden world. And hunker down.

For whatever comes next.

The Truth Is...I love Internal Medicine

I have spent a lot of time on this blog describing what bothers me about being a primary care practitioner. And while this is all true...I love Internal Medicine.

I love being the first one to evaluate a medical problem.

I love using detective work and Occam's Razor to take a complicated story and develop a unified and cohesive diagnosis and treatment plan.

I love using all my senses to treat medical illness. To listen, to touch, to see...being a good internist takes all of them.

I love forming long standing relationships with my patients. Getting to know their children...and grandchildren...and sometimes great grandchildren.

I love catching a diagnosis that everyone else has missed.

I became an Internist because I felt it was the most rounded, challenging, intellectual prospect in all of medicine. As my role in this medical system becomes denigrated, marginalized, and abandoned...

I wonder If I will love it as much.

Memories of College

It was the beginning of a new school year. I had just gotten out of class on a beautiful fall day. The sun was shining. The warmth bathed my face as Eric and I drifted toward the student union. We strolled through the Diag and stopped briefly to talk to a girl from Spanish class.

We crossed the street and entered a small courtyard. As I turned the corner I recognized a girl's silhouette out of the corner of my visual field. I looked up. She was 20 feet away. Her head lifted and our eyes met. As she smiled I couldn't help but smile back. We both paused as if our eyes were having a silent conversation.

She said. I'm sorry I didn't feel the same way about you....We were the best of friends though...I did love you in my own way!
And I answered. I know. But it wasn't good for me to continue the way we had.
I miss you.
I miss you too!

And then the moment was over. Eric and I entered the union and her image quickly jumped from reality to the recesses of my mind.

We would see each other again from time to time. We even talked once and went for coffee. But it was never the same. The connection was gone.

As the years pass the memories become more distant. And of all the thousands of joys and frustrations of a year of having my soul consumed and stomped on what remains is so little.

Those few seconds.

At the union. When our eyes met and we smiled at each other.

And the pain was gone.

Snapshots From Childhood

We were feuding. As much as I, a 10 year old, and my eight year old neighbor could. The long hot summer days had taken their toll. My mother was busy at work and my dad had passed away. The nanny/housekeeper was tasked with keeping me busy. We strolled out on the front lawn with baseball gloves. I was Ryne Sanberg and Aurelli was Jody Davis (she thought he was so cute!).

Our game was shortly interrupted by Andy (my next door neighbor) and Tim who had just moved down the block. They were both a few years younger then me and had become fast friends. Currently they were united in their attempts to antagonize me.

They sauntered to the other end of Andy's front yard and started to throw a foot ball back and fourth. Aurelli glanced at me with a sense fof foreboding....ignore them...you know they are looking for trouble.

Andy and Tim quickly huddled for a moment and then made their way towards us. Hey...you want to join our football game. I looked up quizzically. My heart and mind paused and then started to wage a silent war. Aurelli shook her head...but it was to late. I put my arms out and Andy tossed me the football. Go long.

Tim ran off towards the other end of the lawn. I took a few steps back and launched the perfect spiral 20 yards down field. Tim put his arms up and the football hit its target square in the chest on the numbers. It bounced off and knocked him over stumbling to the ground.

Tim jumped up and looked at Andy. They both ran towards me. Andy was the first to reach me...Hey what do you think you are doing hitting him in the chest that way? Tim was close behind. Aurelli, who knew better then to leave us alone, stepped forward as Tim lunged toward me. She intercepted him but couldn't stop Andy from joining the fray.

As we rolled around on the ground Andy's father strode out the front door and grabbed his son under the arms and heaved up on his chest. I was free. Then he manhandled Andy and I and beckoned Tim. Come on...were going to your house to discuss this with your father.

My heart sunk and I was overcome with fear. Andy's father was a good man...I knew that. Tim's father was something different. Angry, belligerent, he never had kind words for me.

Moments later we were standing at Tim's house. Andy's Father knocked and a large sweaty man opened the door. He was over 6 feet, obese, his face a ruddy complexion and trickle of sweat omnipresent on his brow as if he had sprung a leak and was continously dripping out the contents of his brain.

He looked down at me and his eyes bulged. Oh no you don't...you're not bringin that kid inside my house...I hate that fuckin kid!

Andy's father took a step back as the door slammed. He was visibly shaken...shocked. He walked Andy and I back to his house and sat us down. Calmly he explained that we needed to stop fighting. That we were neighbors and friends. That life was to short to be angry at eachother. And that Tim's father was wrong and shouldn't have reacted that way.

Andy and I never fought again. In some strange way we felt bonded by such an odd experience. We were kids. It was simple. Tim's father's reaction was enough to make us think that we were to young to understand this adulthood thing. Better to be kids...play football...have fun...let the grown ups figure out the complicated stuff.

But I will never forget the vulgarity. The pure hatrid in those bulging eyes. It's probably been the only time in my life that I have experienced such venom directed solely at me.

Long after the memory of the houses, the faces, or the neighborhood fades away.... the hatred...the hatred is what I will remember.

How To Find a Good PCP?

I was reading a post this morning on Health Beat on CMS's attempts to create a "Physician Compare" website. The idea is that our government will create an easy and accessible site that our patients (ie customers) can go when searching for a physician.

Such information as medical school attended, years of practice, law suite history, and location will be available as well as data representing quality indicators.

I have very mixed feeling about such a site. While on the surface this looks like a good idea....I would challenge my readers to come up with a series of data points that would define what makes a good primary care physician.

Sure...you say...easy. They have to be nice. Communicate well. Have a clean office with good personnel. And oh yah...they have to be good at doing that doctor thing. You know that thing where they diagnose and treat patients correctly. Where they balance the existing medical data, each patients unique situation and needs, and yes even cost effectiveness to come up with a tailored plan.

That so called "doctor thing", which I would argue is the most important quality indicator, is just not so easy to measure. Especially in primary care.

Yes we can tabulate how often Dr. X's perscribes colonoscopies. And how Dr. X's patients Hgb A1c's usually range. We can see how close Dr. X gets to the correct blood pressure goals (even though depending on the data each year these goals are revised!).

But none of that really says a stinkin thing about quality. Sicker, poorer, less educated patients tend to be less compliant. I can offer every patient that walks in my door a colonoscopy but that doesn't mean it will get done.

And then there is the problem of gaming the system. Create quality indicators and physicians will be great at bumping the numbers but what will be ignored at the sake of quality. I know you are having chest pain Mr. Jones...but when was your last colonoscopy? Why is your a1c so high? As seen in England, incentivize physicians to ask certain question and do certain tests. They will be compliant. But it will divert their attention from other important issues.

Lastly, how is the government going to attain such data. Up to this point, medicare is incentivizing physicians to report quality indicators with programs such as PQRI which give bonuses for voluntary reporting. The carrot, however, will become a stick in years to come when physicians will be penalized for not reporting.

So...take beleaguered, unhappy, primary care physicians who are already in shortage and overworked, add more reporting requirements which will take up more of their time and add to their overhead. And see what the future will bring (hint....many less PCPs..which I guess is OK if you don't value their worth!).

The problem is that the number one indicator of physician quality (in my humble opinion) is diagnostic acumen. And that...that my friends is exceedingly hard to measure.

So how do you find a good PCP?

I have no flippin clue!

But if any of you figure it out could you please let me know.....It's hard to find an excellent pediatricians these days!

Are PCP's The New Nurses?

It happened again last week. I received a consult note in the mail. My patient had seen the cardiologist for a follow up on cardiac disease. As I perused the assessment and plan I came across a new entry in the problem list:

1) Dizziness: refer to neurology

As opposed to yelling at the cardiologist and demanding that he refer patients back to me for work up....I called the patients daughter. I explained to her that dizziness can have many causes and only a small percentage of them are neurological. Although, of course, I trust the cardiologist could she have her mother please come see me first before going to yet another doctor.

The mother and daughter dutifully appeared days later. After a few minutes of questioning and a basic physical exam the cause became obvious. She was orthostatic and dizzy upon first rising. Her blood pressure was 90/60. I cut back on her cardiac medicines and followed up by phone two days later. Like magic....her dizziness was gone.

I can't tell you how often this happens. Cardiologists refer my patients to neurologists. Neurologists to orthopaedists. Orthopaedists to ENT. And often if they would just refer back to me I could take care of the problem much quicker (it can take months to get into a specialist) and often with less diagnostic testing.

I am not saying I can handle every issue...but usually I want first crack at it. Because I know the patient, I know the medical history, and I know the meds...I am much less likely to disturb the balance of chronic medical issues when treating somehting new.

But that's the problem with primary care today. We are not seen anymore as the problem solvers. We have lost a great deal of respect from our colleagues and patients.

In some ways I feel we have gone the way of the nurse. Much maligned by both physicians and society, nurses continue to toil behind the scenes with great amounts of knowledge and ability. It's just no one recognizes it.

Some days I am the cardiologists nurse, some days the neurologists, other days the dermatologists.

PCP call the pharmacy and order another months worth of medications
PCP insurance requires a requisition for that test
PCP write out a referral to another specialist because I can't figure this out
PCP the patients dying...go talk to the family about hospice!

Some Thoughts On Hospice

Friday in my office is like happy hour.....for the oldest of the old. They come. 90, 95, 100. Always on Fridays. Some come in wheel chairs. Others walking. Some alone. Others with family. 5,6, 7 sometimes even more in just one short morning. And we talk...about life, about their children, about growing old. I apologize that at that age I really have little to offer. After all... they know more about health then I....they made it to their ninth decade. Some I offer comfort, others medicine, on rare occasion tests. Mostly I just listen.

So it is fair to say that I am used to dealing with geriatric issues. And it is also fair to say that I work closely with hospice and find it one of our best resources in dealing with end of life care.

In reality, my medical training started with hospice. My first clinical experience with real "live" patients was as a hospice volunteer at the beginning of medical school. I started in the inpatient hospice unit. I did everything from laundry, to comforting families, to helping the nurses place dead patients in bags in preparation for transport to the funeral home. Eventually I traveled to patients houses to help with chores and run errands.

Yesterday I signed three death certificates. One died in the hospital of acute illness. Another died in his home with his wife and family present. The last died in an assisted living. They were all hospice patients but each for less then a week.

And I figure these numbers are about accurate. Probably 95 percent of my patients die in hospice. Likely only 10 percent die in the hospital. The other 90 percent die at home or in a nursing home or assisted living. Most of these patients have only been in hospice for a short period of time.

Often when I talk to my hospice colleagues I feel a slight sense of reproach. The conversation ends with a statement to the extent of, "to bad your patient couldn't have enjoyed these services for a longer time period."

I understand these sentiments. I do , in fact, believe that patients with terminal diagnosis live longer with hospice care then traditional management. I do believe the quality of life is better. But the truth is that most of my cases are not so black or white.

Some die of acute illness and the time period from decompensation to death is short...hours to days.

Often my elderly patients and their families are not emotionally ready early in the disease process. It can sometimes take months of conversations to help a family understand that their elderly loved one is slowly fading away from dementia.

Sometimes a patient has chronic illness like COPD or CHF and it is unclear if death is around the corner or a few blocks away. Often I avoid hospice to allow for the agility to move from palliative mode to acute aggressive care without having to explain to a hospice administrator why I want to spend money ordering tests on a patient who they think should have a less aggressive course.

And sometimes I hold off on hospice because the patient is comfortable. The family understands and every ones needs are being met.

I will continue to value hospice services. As time goes on I see the movement flourishing. It is becoming more agile. Moving from palliative to comfort care and back again.

The possibilities are endless.....

We are entereing the golden age of hospice care!