Ice Skating

It's been a hard week. After 13 days straight. Getting up at 5am and pulling myself out of bed every morning as the rest of the household sleeps. One of those weeks I would rather forget. Lots of regret. Lots of worry. And certainly heartache.

And even on my day off it continued. A quick call to the ICU confirmed what I had feared all along. As the tension in my neck became unbearable the headache set in. My mood soured. My wife cautiously appraised me from the drivers seat as I became quiet. The kids argued in the backseat.

I had had enough. By 5pm I was ready to shut the world out. Close the doors and turn of the lights and call it a day. But there was a birthday party for my son and daughter. Of all things an ice skating party. And I didn't have the heart to stay home alone.

So we dragged the kids into the car. Put them in their car seats. Made our way to the skating rink.

My wife rented skates for herself and the kids, and I moped on the sidelines. As I walked into the observation area the cold air whipped across my face like a slap. It woke me up. It bayed me to come.

I walked hurriedly out the door and back to the check in area. I grabbed an old pair of beat up skates and raced to the rink. I laced up the skates with great clumsiness and inefficiency. Being that I had only skated once in the last twenty years I wasn't all that confident in my abilities.

I gingerly inched out on the ice and something amazing happened. My mind became totally engrossed in the activity. My neck muscles relaxed and my shoulders loosened. My legs moved rhythmically across the ice as my body swayed back and forth with each kick.

And I forgot. I forgot the horrendous sadness I had encountered last week. I forgot the sorrow and fatigue and stress. For a second I let go of the complexities of adulthood....of being a physician....and I was a child again. swirling through the air with ease and abandonment.


Free, simple, and in the moment.

Memories Of My Father

My spindly legs dangle absentmindedly off the bottom bunk of the bunk bed. It was Michigan or Wisconsin or somewhere close to Chicago. I gently lean back on my wrists almost touching my father who is lying comfortabley next to me. He pulls on my arm and I fall backwards and land in position next to him.

We chat easily. I am six years old and this is my first trip alone with him. I watched earlier in the day as he stood at the podium. What seemed like thousands of Men and boys had gathered each in groups of twenty around the room. All wearing leather vests with patches and little halo's of feathers.

It was called Indian Guides...a chance for fathers and sons to spend time with other fathers and sons. To this day I can't remember exactly what we did at those meetings. Once my friend Chris and I had a contest to see who could drink the most punch. At the end my father had to pick me up and run to the bathroom so I didn't vomit on the floor.

Every year the Indian Guides would pack up and go to a special regional meeting. Usually somewhere in the Midwest. And this was my first year. My dad had somehow been elected the "Regional Chief". So while the other kids stood by their fathers I watched mine speak at the lectern. He finished the business of the afternoon and we adjourned to our cabins for rest.

Lying in bed next to my father I feel sweet fatigue wash over me. We talk about the meeting. At one point there was a shouting contest between the different "tribes". I think ours is the loudest but my father, the judge, has not yet made up his mind.

I drift off.

And to this day I have few other memories of that weekend. Few other memories of my father for that matter.

I would return to the cabin a year later for the next meeting. This time I was accompanied by my uncle.

In the interim...ofcourse....

my father had died.

My Manuscript Primary Care

I am pround to announce that my manuscript of poetry (chapbook), Primary care, has been accepted by The Lives You Touch Publications. It is slated for publication in winter 2011.

Why I Always Knock

It was a time before EMR's. A time before healthcare reform. And I was a new physician. In a new practice. Wet under the collar and trying to build my own brand...my own style.

So I broke tradition. I went against the grain. I separated myself from all the other physicians.

It was a big step......

I implored the medical assistants to please keep my physicals clothed so I could interview before the patient was forced into one of our oh so flattering gowns.

But Dr. V doesn't do it that way. Dr. B doesn't do it that way. They chided. Dr. G already making waves in the new practice.

But that was me....making my mark. Changing procedures and saving lives.

And they said they would follow my directions. Sure they sniggerd in the corner....but I was the doctor....the boss. They listened to my preferences and acted according.

I remember that first week in practice so well. Every patient was a learning experiance. Every encounter refreshing and new.

And my first physical. A young woman in her twenties. I burst into the room with hand extended ready to greet my new patient.

She stood still like a deer in headlights. Completely naked with her gown outstretched in one hand. Our eyes met and we both blushed....and then she held the gown in front of her body and crouched to cover as much flesh as possible.

I mumbled a quick apology and backed out the door. The medical assistants standing at the end of the hallway saw my rapid exit and began to laugh even though they didn't even know what happened.

They would eventually.

And they would never forgot to room my patients clothed again....

And to this day when faced with a closed exam room door...

I knock....

Pause.....

And then enter.

On Being a Father

There was a time. In my youth. When I was confident and stood boldly in front of the fear and tyranny of longevity. And I stared down death. Without wincing. And proclaimed my superiority. Because I felt as If I had accomplished enough. I can still hear the the immaturity and naivete in my voice...If I were to die it would be OK.

And then I got married. And all of the sudden there was this other being. Who I depended on....who depended on me. And I was no longer so loose with my own mortality. For death then became an enemy. Not a raving lunatic scratching at your front door but more the lurking phantom in poorly lit allies and quiet corridors. And yet I still heard that calming voice....If I were to die today...If she were to die....things would be OK.

And then I had children. And I spent countless nights awake worrying...and holding...and comforting. These children, a product of my own creation, grew and flowered before my eyes. They developed souls and personalities. We laughed together...they jumped into my arms when they were hurt.

And I felt content. Or at least for a moment. Until the specter of death reared its ugly head again. Not as a concrete concept but more of an abstract. A what if. My previously conquered opponent was back and had a new weapon. My Achilles heal.

Those sweet beautiful children. My life's work wrapped into those little needy hands and feet. How can I now live in a world that could threaten them..that could threaten me. Because when you have children you are turned inside out. You expose yourself to the barest most sensitive parts. A million nerve endings clumped together into the small space of a fingertip.

My confidence is gone. My acceptance of life's trivialities and foibles and the fecundity of mortality have overwhelmed me. I am despondent. Torn between the utter joy and uncontrollable fear of being a father. If I die...as my father did....It is no longer OK. And if something were to happen to my children......

See that's the thing about becoming a parent. You give up everything. your heart...your soul.

I will never be completely at peace again.

And in my new maturity...my new reality

That...that is what has become OK.

I'm Coming Home

As the door opened the look on her face was undeniable. Grief. Pain. the tears rolled down her eyes. She let me into her small dorm room and hugged me. And then she told me that her grandmother was dead.

She was a mess. Her sadness was overwhelming. She sat on her bed in a stupor. And I sat with her. Holding her hand. Not saying a word. Just being.

I sat a few minutes minutes. I sat for hours. At two in the morning I returned to my room and went to bed. I cleared my books and climbed under the covers. And for a moment a worried thought crossed my mind.

I wouldn't be prepared for my exam the next day. The last few hours were supposed to be devoted to studying. Instead life had interrupted. Not my own...but a dear friends.

I sleepily took the exam the next day. One of two exams for the whole semester. And I did terribly.

It was my worst grade in all of college. My one blemish in my perfect medical school application. But it was OK. I really didn't think much of it. Back then I was that kind of person.

As I was rounding this morning in the hospital this memory came back to me. I had just left the room of a patient who was recovering from recent surgery. Although the last few days had been fraught with difficulty...she was finally turning the corner. I had assured her that medically nothing needed to be done. Just time...optimism...and hard work. She replied..."I know Doctor G....you somehow always have a way of making me feel better!".

Now sitting at my computer I am thinking a lot about this interaction. Because strangely...undeniabley...what I have done most for this patient has nothing to do with my medical training. I have not diagnosed any disease nor rendered any life saving treatment. I have delivered basic humanity...kindness..reassuramce. Dare I say love? It feels similar to that late night in the dorm room holding my friend's hand. Telling her that everything would be OK.

This humanity...this generosity..is something that almost feels like a long lost friend. Before medical school. Before my brain became clouded with algorithms and formulations. I was just a plain human being. Struggling against a cold, lonely world by practicing basic kindness. Delving into the human morass to connect with my fellow man.

But something happened to this humanity. Maybe it was the staunch self preserverance brought on by medical training or the selfishness of young adulthood and building a career and family. I somehow became a shell of the person I used to be.

Or maybe there is something about medicine. When you get paid to be a healer...a supporter of life...maybe you lose the innate drive to connect outside of your professional life. Maybe when you become an expert at being there for people, your generosity is most at risk. After all, generosity is often defined by the absence of obligation.

I once wrote a story about a father who had to go to extraordinary lengths to save his child. In the end his son dies anyway. In conclusion I wrote:

even those who walk on water occasionally find themselves stranded in the middle of the ocean. It was time to grow up. He could either let his sadness drown him or he could learn how to swim. So Derek abandoned his superhuman qualities......

and dove into the murky abyss

As the protagonist in the story maybe I also have to abandon the physician's super human qualities. Maybe it's time that I dove into the murky human abyss and returned to the generosity of spirit that led me on this life path in the first place.

Maybe it's time that I returned to the beginning.

Back to the person I used to be...

I'm coming home.

Dear Mr. President

Dear Mr. President,

I know that over there in Washington you are surrounded by countless health care experts, gurus, academic and nonpracticing physicians. I know that you have had your fill of opinions from almost everybody...but I was hoping to add in just one more. You know...the opinion of the lowly primary care doctor in a small private practice. The kind of doctor that at one time made up a majority of the physicians in the United States. I know I am still quite young...but maybe I have became the dinosaur. Either way...my kind will be extinct soon.

We hear from the media and the government all the countless benefits of health care reform. I thought you might want to know what is actually happening on the ground. To those working in the trenches and providing the actual health care.

Profound changes are afoot. You have revolutionized health care. And I hear you. I know you want to beef up primary care. How important you have told us it is. I even enjoyed my frst 10 percent bonus check recently. Well actually 8 percent (after you cut out co pays, and secondaries, etc). Well actually more like 5 percent if you include medicare hospital work for which we don't receive the bonus.

But I think you ought to know...as a practicing primary care physician...my job is actually getting harder since the changes. Less enjoyable. More full of paperwork. Maybe I can provide a few examples.

Medicare came up with the brilliant idea to cut down on home health fraud by making sure that each patient needs a documented face to face visit and a physician to sign off before home health is provided. This is great. Save money. But did you ever think about who would have to fill out all these forms?

Yes each form only takes about 1-2 minutes. Doesn't sound like much. But when you do this day to day over thousands of patients it gets tiring. Just added work. It's great that you want to cut down on fraud. But why do I have to be your police force? Why do I have to use uncompensated time to do your dirty work? You know the specialists won't fill these forms out...they turf it to the good old primary care doc. I know what your saying now....well you get to bill for the visit. But I was seeing those patent's anyway. If they were sick enough to need home health likely I had seen them in the office/hospital/nursing home in the last few days already. More paperwork. More time. More hassles.

And lets hear it for EMR's. Your incentives to get them up and running is great. In fact over the last few years we have payed over 100k to have ours implemented. Recently my company misys/allscripts has written us that for only 15k more we can be prepared for meaningful use. Great...it should be easy if I get that incentive payment from the government to pay for that investment. Never mind that I already spent 100k in the first place. Never mind that if this is anything like the pqri program only 50 percent who try for it will actually get payed (and then what a colossal waste of money if I don't make it). Never mind that to read through the meaningful use criteria and fully understand it will either take a large investment of time (hundreds of pages of minutia) or an expensive consultant to actually use the system meaningfully.

Speaking of EMR's my hospital has been on the forefront of implementation. I have been using Epic for years. The quality Guru's now tell us that med reconciliation is by far worth the bang for the buck. So our hospital has now implemented a new med reconciliation tool. This will help the hospital track such important quality indicators such as "aspirin use at discharge for cad patients", "or smoking cessation counseling". This is wonderful. In concept. In reality now I have to fill out three forms as opposed to one when I discharge a patient. Med reconciliation adds 5-10 minutes to my discharge process. No problem...unless you are trying to discharge 3-4 patients at once. I have even seen less scrupulous physicians...especially when covering for a partner...keep a patient an extra day just so they wouldn't get stuck with the laborious discharge paperwork.

And by the way...the specialists are getting incredibly good at handing off the extra work. I got a call yesterday from one o the floor nurses. Dr. X says that his uncomplicated elective post op hip replacement is OK to leave the hospital and go to the SNF. "He is asking that you do the med reconciliation, discharge instructions, and COC form...his PA says they are not qualified to do this paperwork."

Then don't forget the new rules on narcotic prescriptions and hand written scripts....boy this has made taking care of nursing home patients fun!

I could continue with more examples.

In the near future I will likely have my rates from medicare cut significantly for eperscribe, pqri, meaningful use...the list go on and on. Some of these initiatives I will be able to comply with. Others I won't. My bet is that even if I try I will be found non compliant by medicare for one reason or another and not get my incentive bonus. Each of these incentives will cost money and precious time to implement. Time taken away from patient care. What medicare giveth (a 10 percent bonus in primary care) it will find another means to taketh away (pqri, eperscribe, meaningful use).

I think I speak for a large portion of primary care physicians in saying that what we see coming from ACA and the government scares the heck out of us. Already our work loads are increasing. Already we are being pushed to do even less hands on patient care and even more laborious paperwork.

I became a physician to help people...not to do paperwork...not to do community health....not to become the read headed step child of medicine. Just me and the patient. My ears, my hands, my pen.

Most of the people excited about health care reform are the ones who don't actually practice it day to day. Administrators, politicians, academicians, consultants, medical students, public health experts. They don't have to walk a milke in my shoes.

When medical students ask me about my choice of speciality I say...it is the most rewarding field...but I certainly would have never chosen it knowing what I know today.

When my children ask...I exhort them not to become a physician.

I hope this opinion finds you well and adds to the plethora of voices whispering in your ears.

Sincerely....and with profound regret

A dinosaur soon to become extinct

Jordan