Just Sayin

We have to stop comparing ourselves to the airline industry.

Sitting on the lounge chair at the pool, I can't believe that just hours ago I was sludging the wintry streets of Chicago, rushing to the airport.  The kids clucked away happily in the back seat as the adults in front where more subdued.  As grownups do, we kept running through our mental checklists even though the ship had already sailed, we left the house.

The trip, in general, was quite smooth.  With the exception of seating.  For some reason, even though we had made the reservation months in advance, the four of us were sitting in completely different rows.  Now, although I miss my wife dearly even when the separation is just for four short hours, for the little ones sitting by themselves just wouldn't suffice.

At the baggage check in, the clerk said there was nothing she could do and asked us to wait until we arrived at the gate.  At the gate, they blamed the airlines new computer system and unsuccessfully tried to convince other passengers to switch seats with us.  They refused.

While boarding the plain, I really started to wonder why we in the medical industry want to model ourselves so badly to the airlines.  There are so many things the flight industry gets wrong.

Let's think about this.  How often do flights run on time?  How often are flights cancelled?  Why is it that baggage gets lost on a regular basis?  Why was it so hard to seat me with my young needy children?

The truth is, there are problems so complex that even the airline industry can't solve them.  Sometimes, no one can predict how a cold front over the Atlantic will affect an intricate and interchanging landscape of schedules.  Things get lost, there is human variability and error.  And new computer systems sometimes aren't programed how they should be, or the end user is not trained to use them correctly. 

What becomes ultimately clear, is that human beings especially, do not follow a manual. The number of interconnecting parts are too great.  The whim of human frailty is largely a mystery.

So there are successes.  Airlines are great at making checklists for highly controlled situations where mechanical failures occur in flight.  These failures are knowable, predictable, and often amenable to corrective measures.  I would say that the medical field of anesthesia (also a highly technical field) has had similar success.  But for most other types of medical practice, as well as for the airline industry, we are plain lousy at dealing with the incredibly complex field of human (and climate) diversity.

When we finally got to our seats, a courageous young man looked at the four of us, and willingly moved so a mother could sit with her young children.  After all that wrangling, the answer became obviously clear when the involved parties were face to face with the reality of the situation.

Oh, and by the way, medicine is nothing like the Cheesecake Factory either.

Just sayin!

Can We Calculate The Price Of Human Dignity?

I never claimed I was brilliant.  I never bragged that MENSA representatives were knocking on my door and pleading for me to join.  But I am smart enough.  Smart enough to matriculate medical school and residency.  Savy enough to own and operate a business.  Lucky enough to be married and have kids. Most difficult projects in life require hard work and a certain amount of stubbornness.  And I rejoice in that I have been given the mental faculties and vast opportunities to succeed.

I reluctantly admit, that I have always found a way around most of the hurdles in my path.  I either jumped over, ducked under, or swerved to the left or right.  Occasionally, I turned and ran the other way.  Nothing extraordinary here.

Recently, however, everything has changed.  I've met my nemesis.

It takes the form of a colossus of metal, rubber, and a little bit of padding.  One can see it hocked on the Internet, and in infomercial like segments with elderly people cheerily scooting around with smiles on their faces.

Yes, I'm talking about power wheelchairs.

Now, in general, I'm not a fan.  Of the thousands of geriatric patients I take care of, I may have ordered twenty in ten years of practice.  Occasionally, no matter how much I don't like them, some patients are so disabled that there is no choice.  As their doctor, I want to help these patients.  I want to protect them from falls and increase their mobility.  I want to restore a modicum of dignity through the wonders of lost agility.  I want to be a Doctor. 

But no matter how I try, every order I have written in the last 6 months has been denied by Medicare. 

It's not that I don't understand.  Fraud happens, and these machines are expensive.  So I get that in order to have this kind of service covered, a face to face evaluation of the patient must occur documenting the disability and the reason for the need.  I get it!

Unfortunately, I can longer traverse this process without messing it up.  Either I document too thoroughly...or not thoroughly enough.  My review of systems is inadequate or my review of systems is too adequate.  One patients note did not describe to enough detail the weakness requiring a power chair.  When I addended my note and clarified, I got a denial message saying that the patient was to weak to maneuver the chair.

Huh?  So this poor, frail, elderly person who has been tripping over her walker because of inadequate strength will not be able to move her hands enough to operate a joystick? Really?

We often use the word draconian to describe the clunky nature of governmental regulation.  The collateral damage of dealing with small amounts of fraud is often greater that the cost savings from such measures.

My unstable octogenarian will not get her power wheelchair.  Instead she'll trip over her walker and land in the hospital with a broken hip.  Instead of a five thousand dollar piece of medical equipment, the bill will likely be over fifty grand.

Let's not forget the cost of a hundred covered days in a nursing home.

And can we calculate the price of human dignity?

The Mice Keep Running

It had all been so easy when Jim was still around.  Lisa's ex husband had many shortcomings, but being a critical care specialist sure came in handy.  Any time her mom or dad had a health crisis, he was right there in the middle of it: advocating, interpreting, breaking down the complexities into easily digestible morsels of information.  But then Lisa's father died, and the emotional and physical stress brought the unstable union to a breaking point.

Years later, she sat in the ICU holding her mother's hand and longing for the man that she had grown to despise.  She felt a slight tenderness stir in her heart that was suddenly extinguished by picturing her previous husband with his new, almost teenage love interest.

Damn!

Lisa's mother suffered another stroke.  The ventilator had been removed but her mental state was dubious at best.  She was not eating.  And the hospitalist was suggesting a feeding tube.  Lisa recoiled.  Her memories of her agitated grandmother socked away in a nursing home pulling on the plastic protruding from her abdomen was too much a burden to be replayed a generation later. 

If only Dr. Phillips would come to the hospital.  As her mom's primary care physician, Lisa trusted him.  But he abandoned his privileges years ago.  He once confided that he no longer knew how to take care of such sick patients.  Lisa missed his optimism and his gentle hand on her shoulder resting tenderly.  He understood her struggles.  The hospitalist was nice enough, but young.  He seemed overly concerned with protocol and rarely spent more than a minute in the room without leaving to answer a page.  He certainly had no advanced knowledge of the woman lying in the bed in front of him.

The family meeting was pathetic.  Instead of the hospitalist, a palliative care nurse joined the social worker and other supportive staff.  Thirty minutes later, Lisa walked out more confused than ever.  Most of the conversation resolved around disposition: nursing home, home with hospice, or rehabilitation center. Each member had their own checklist of salient decisions that often seemed far removed from her mother's wants or needs.  There was no question who each participant worked for.  The hospital, the government, anyone except for the poor helpless struggling patient. 

Lisa thought of Jim again.  If only she had an advocate.  Someone who answered to her and her mother instead of the litany of outside interested parties.  If only her doctors would lift their heads from the computer screen for just a few moments.  If only someone with medical knowledge took a moment to see the forest from the trees.  

The mice keep running through the maze trying to find the elusive cheese.

Damn!

What the hell has happened to our medical system?

The Gift That Keeps Giving

An Imaginary conversation spoken softly in a plush office behind closed doors.

CEO: We really took a hit fourth quarter. Why were the numbers so bad?

CFO: Well, acquiring SER (small EMR company) tightened our cash flow, and we have yet to convert those customers. 

CEO: Convert? When's that press release going out?

CFO: By next week.  It will take a few months for the clinicians to realize that their platform is being discontinued.  Our upgrade, which will cost roughly thirty thousand a physician, will be ready by March.  I figure we'll convert ninety percent given it would cost double to implement a new system.  We can also sneak in some upgraded hardware.  That could increase profits by ten percent. 

CEO: Ha!  They have no idea what's about to hit them.  What about that big account we just lost?

CFO: Government regulators shut them down.  Something about inadequate documentation.  Really a tragedy.  It kills our customer base a bit, but all those patient records need to go somewhere.  I think we may be able to package up the platform to their competitors.  That should make it easier for them to gobble up all that new business.

CEO: And of course, there's meaningful use?

CFO: Yep!  Now that the new rules are being finalized, we can role out a bunch of upgrades.  Money in the bank.

CEO: Meaningful use.  Huh.  The gift that keeps giving.

CFO: And giving, and giving, and giving.

Transience

I'm flawed.  Deeply flawed.

Sometimes it's hard to remember that in the la la land of blogging where everything is clean and tidy.  I'm a representation of myself.  It's much more pleasing to turn towards the unsplintered side when the camera is on.  Best to avoids the cracks.

Patient care can also be like this.  The surly octogenarian squints at me through beady eyes as she shifts in her seat.  The remnants of chewing tobacco spit out around her over sized cheeks while talking. She is gruff.  Her belly hangs over her waist supported by small spindly legs.  Her language is thick and colorful.  Only the most superficial would mistake her for a dolt.  Her wealth, gained and lost many times, the symbol of a savvy forward thinker.  She unloads into a cup and smiles in my direction.

You're my mentor.

I get her meaning.  She is thankful that I made the diagnosis that the emergency room physician missed.  A few days of steroids and her lungs are better than ever.  It wasn't the first time the aged, beaten body had unexpectedly bounced back.  In a short few years there had been hospital stays and nursing homes, emergency visits and family meetings. I had been there every time.

And I wonder what she will do after I leave.  Not exactly uncomfortable, I am unable to stay too long in a position that I know is unjust.  I will sacrifice my gift to stand up for a principal.  Whether my intention or not, I will live and die for an ideal.  That, I think, is my path.  My awkward, flawed path.

But there are times that transcend the humanness: the seconds where the exhaustion of exercise gives way to one more burst of activity, the illuminesence of my children's eyes as they start dancing when my wife clicks the radio on our IPAD, or the rush I get when making a difficult diagnosis. 

For moments the wrinkles and frown lines disappear.  And I am perfect. Fleeting. Broken.  Full of myself.

But perfect.

Perspective And Empathy

I could see through the two window shields into her car.  Her forehead creased into a petulant frown and she mouthed the words over dramatically.

Asssssshooole

Five minutes earlier, I was packing up my papers at the nursing home when my pager went off.  I fumbled for the desk phone, my arms constrained by the bulky winter jacket I had just climbed into.  I tapped my feet and waited impatiently for someone to pick up the line.

Hello, hello Dr. Grumet?  I think she's dying.  Can you come now?

The ICU nurse sounded panicky.  It was early in the morning and the critical care specialist wasn't in the building.  I jumped out of my seat and sprinted toward the car.  The trip was less than a mile.  I turned onto the expressway and then made a right onto to the nearest exit.  I stealthily navigated a series of small streets punctuated by a stop sign.  As I came to the intersection another car pulled up facing me.  Seeing her right turn signal and knowing I was going straight, I made a superficial attempt at stopping and then rolled through.

While passing, I could see the anger seethe from her lips for my failing to abide by the most basic rules of the road.  She was furious.  I felt like laughing.  If she only knew that I was racing to the hospital in the most dire of circumstances. 

It was a matter of perspective.  But I couldn't be too angry.

Hadn't I been just as guilty?   How many times had I shook my head disapprovingly as an elderly patient hobbled into my office thirty minutes late?  Had I fumbled with the icy certainty of arthritic joints or the Himalayan distances crossed in the parking lot, maybe I would understand differently. 

It is shockingly easy to regret the futile decisions of  a panicking family when it's not your loved one lying in the hospital bed.

Perspective and empathy.  Different sides of the same coin.

The women in the car was right. 

I had been everything she hauntingly accused me of.

At times. 

The Five Stages of #hcsm

It all started with denial. 

I mean, I'm a doctor.  Who has time to be clicking away on a mobile phone when there are patients to see?  There are only so many minutes in the day.  And what is there to gain anyway?  I don't need more friends, I need to be reading journals.  I need to be studying for boards.  I need to be building my practice and meeting colleagues. 

Yet I have a voice, a viewpoint.  Certain things need to be said.  How can I be heard?

But then anger set in.

Everyday I bang away at the computer and bust out content, blogs and tweets abound.  Yet post after post no comments, no followers.  All I do is give, give, give and get nothing in return.  I want to be notable, a superstar.  At this rate all I'll be is a foot note.  My writing, my words will be lost in the diaspora.  So why do I keep going?

The bargaining phase was inevitable.

If you follow me, I'll follow you.  I retweeted you...how about some love back?  Your writing is amazing, I blogged about the same topic the other day. 

Then, of course, depression.  Desperately curt, poignant depression. 

Why bother anyway?  No one cares.

Somewhere in the darkness: sweet acceptance.    

I write because I have to.  The connections I've made are lasting.  I learn, I grow, I'm lifted by the brilliance that surrounds me.

And then denial creeps back around the corner.

Maybe I should go back to concentrating on being a doctor and not waste my time on such things.