Your Fly Is Open

There's a good deal of soul searching that takes place in the exam room.  I see every flavor of strength and ugliness of the human character, sometimes all in the same person.  This strange mix of human suffering and superlative psychodrama have an effect on a guy.  After a decade of chasing this calling (and reaching toward a new number in the tens column of my age no less), I spend a certain amount of time trying to decide who I am. 

Now, it's fairly easy to dispel of the white night thing from the beginning.  Although a doctor, I'm no angel.  At times, my patience runs short.  I have had my moments of combativeness with my colleagues and proffered many apologies.  I am human with all the trimmings that come with the scarred irregularity of humanity. 

In this, my patients and I are the same. 

It's hard enough coming to the doctor's office with one's body broken and diseased.  It takes a small part strength and a large part courage to bare one's emotions to the stranger sitting across the table.  How awkward it is to undress and slip on one of those skimpy gowns with the strings that never seem to tie appropriately in the front or back?

There is enough embarrassment.  So when a patient is dressed and the counseling is over, if I happen to notice and open fly or a shirt that is sloppily untucked in the back, I mention it.  I come right out and say it no matter how my face may flush or how awkward the following silence may be.  In fact, I do this outside the exam room too.  Because I would want someone to tell me. 

And maybe in this, I have finally found a definition that suites.

Who am I?

I'm the guy who'll tell you your fly is open.

Every time. 

Bravery And Consequence

There's been a lot of patting on the back lately, and telling me how brave I am. 

And usually, I shrug my shoulders and bask in the glow of approval.

Lately, however, I feel more like a coward.  I hunker down in the exam room and shield my psyche from the initial reaction.  Brows furrow and words come out faster than mouths can speak.

You're leaving the practice?

Wrinkles become smooth as I explain the new paradigm.  What's there not to like: less patients, home visits, more proactive care.  Once again my nerves unwind, yet I know the moment has come.  The tone changes as we get to the yearly fee.  While it doesn't phase some, I can see the gulf form in others.  Eyes turn dead and dart towards the ceiling, expressions become frustrated or just plain angry.  They know they're being left.

I didn't have to do it this way.  I didn't have to start this early.  I could have just kept my mouth shut and waited to send a letter.  But that wouldn't be me.

I will stand before each and every patient.  I will tell them face to face.  I will accept their reactions whether joy or disgust, because I owe it to them.

I made this decision willingly,

I won't cower from the consequences.

Zero Sum Game

This is what I tell my patients...

The world is changing for providers.  Heavily medicare weighted, the last few years have seen a proliferation of administrative paperwork.  When not overwhelmed with forms, we are hunched over computers inputting inane information like race and ethnicity.  What we are not doing, is taking care of patients.  We are not interfacing with those that we have sworn to care for.  The covenant I have so often written about is being replaced with vague ideas of community health and meaningful use.  In no uncertain terms, we are letting you (the patient) down.  This makes me ill.

A few months ago, I had a crisis of conscience.  I could no longer sign off on this willful subjugation of the doctor/patient relationship.  So I crunched the numbers.  What I found shocked me.  Most of the revenue from my practice comes from nursing home work.  In other words, all those hours spent in the office and the hospital did exactly one thing.  They paid the bills for that very office and all my employees. It's a zero sum game.  I would be better off economically if I finished each day at nine am in the morning.

So I decided to radically change the way I care for people.  I will continue to go to the nursing homes, but I am also opening a micro practice.  Trading in my two thousand plus patients for a few hundred.  In fact, I am mostly contemplating visiting people in their homes or places of business.  My patients will have my cell phone number and email address.  When they call the office they will get me, not some nameless, faceless employee. Care will be more proactive and patient centric.  Technology like skype and face time will bridge the gap.  I will once again be able to devote the time and energy necessary for every single soul under my care.  I will still be forced to do paperwork, but when your patient load is a tenth of the size, the time consumed is much less significant. 

Of course, there are drawbacks.  To support this micro practice I will charge a yearly fee that is not payed for by medicare or private insurance.  This fee will subsidize all those individualized services not covered by traditional models.  The doctors in my area generally charge X for this type of service.  I will also charge X, but I will see you in your home or place of business instead of the office. 

In a few months, you will receive a letter in the mail outlining the details of my venture.  I invite you in joining me in a revolutionary and patient centered model of health care.  For those who decide not to follow me in my future pursuits, your medical records will remain here and one of the doctors in the office will be happy to pick you up as a new patient.

Thank you for placing your trust in me.

Death Is Often Quiet

It is one of the most difficult things for lay people to understand.

Usually there is a moment to collect my thoughts as the phone rings.  I speak slowly and deliberately.

Something has changed.

They are carefully chosen words to cushion the unavoidable plunge into darkness.  I know. I know. 

It happens dozens of times a year.  Death follows me home after a hard day of work.  It buzzes against my skin and awakens me from a deep sleep.  It yanks me out of exam rooms and interrupts family dinners.

Such irony for a boy excused from class in second grade to be accompanied home by a family friend.  My mother pulled me in close and whispered that my father was gone, even as relatives sat in the living room glumly.  But now I have become my mother and guide families through this awful blackness. 

I wonder how it affects me.  While others struggle with shadows, I see quite clearly.  My eyes have adapted so expertly that often I feign empathy as friends relate the tragedies of the day.

I didn't know my career would lead here.  I didn't know that I would be good at it.

I pray, my dear reader, never to meet you in this lonely place roaming beside me.  But, if I do, I might offer a bit of wisdom.

Death is often quiet.

Pain should be the exception, not the rule.

And suffering, it turns out, is mostly left for those who remain.

My Interview With Mike Sevilla

If you have some extra time, listen to my interview with Mike Sevilla on Blog talk radio here (1 hour interview).

Or for a short clip at the end of the show go here.

Will They Follow?

It hurt, more than I was ready to admit at the time.

John walked into my office years ago with a stack of papers under his arm.  A few hundred pages to be more exact.  He carried his copy of the medical history like a burden that was more a part of his body than a separate, distinct object.  He pushed it forward onto my desk tentatively. 

There was the usual minutia of any medical record: labs, injections, consult notes. It was a cat scan, buried under reams of repetitive nonsense,  that caught my eye.  The little smudge noticed by the radiologist was a nothing, a ditzel.  But there was no followup.  No further workup.

Originally John was alarmed, then scared.  The biopsy showed a lethal malignancy if left untreated.  I put my arm around his shoulder as he shook.  A week later he underwent a successful surgery and was cured. 

For years he walked in and out of my office on a regular basis.  I was the doctor who saved his life, and he was my patient.  In 2007, I announced that I was moving my practice thirty minutes to the north.  Of all the people, I was shocked to find that John refused to follow.  Without apology, he explained that he preferred someone closer. 

My sense of professional worth dropped a notch that day.

Now, in 2013, I am again asking my patients to make a drastic change. Although I have had nothing but positive feedback, I can't help but feel a tad skittish. 

I will stand alone, exposed, and make my pitch.

But will they follow?

Doctoring Is An Act Of Love

As any well cared for patient will tell you, doctoring is an act of love, not a job. 

In what other relationship do we directly put ourselves in a position of long term responsibility regarding others physical and emotional well being: parents, children, spouse, good friends? 

This covenant has it's privileges.  You become a grain in the sand of people's lives.  Membership is deep and enduring.  Very few are lucky enough to wake up every morning with a sense of meaning and purpose.  In the end, this is what drives people to the profession.  No amount of money, power, or ease can replace human connectedness.

But it's hard.  Not hard like bench pressing two hundred pounds.  Hard like carrying a sand bag on your shoulders for the rest of your life.  Your neck often bends and your posture stoops forward.  When a patient is lost, one would think that the burden is lightened, usually the opposite is true.  And there are always new patients requiring you to forfeit a small part of yourself.

There is often less to go around for others.  Your family and friends, your children, sometimes only get the scraps.  The pieces are what's left at the end of the day.  Your loved ones have also unwittingly made a covenant with every patient that walks through your door. 

If you understand this.  If you see this.  Then it is no great surprise the turbulence most physicians are now feeling.

The filling of forms.  The clicking of clicks.  The reams of checklists, rules and regulations. 

It's turning this great act of love into a job.

A clerical, emotionless, empty job.