They found you in death much as you had been in life.
Alone.
You once told my office manager that I saved you. I shrugged. I couldn't help but feel that I was watching you die day by day. It's not that I didn't try. I fought with you tooth and nail. Begged you to go to the hospital, for anything: a pneumonia, vomiting, I would have been willing to make up a diagnosis. But you told me that hospitals were places that people go to die.
I watched and waited. I scolded that one day I would get a call from the police telling me you were gone. You lived up to that prophecy. I wondered back then how I would feel. I suspected some version of relief. After struggling for months and years, I couldn't help but suffer a certain amount of battle fatigue. I now know more accurately what resides in my heart
Emptiness.
Something strange happens when people let you into their lives. You struggle through their peaks and valleys. You become soldiers in a common battle. In many ways they become a little part of you. The hazard in this profession is letting too many people in.
Because they all die eventually.
And tragically, predictably, a special piece of you goes with them.
Tuesday, May 21, 2013
Saturday, May 18, 2013
Embrace The Joy
It's not exactly Dr. Jekyll and Mr. Hyde, but everybody knows my level of patience varies from time to time. So I was surprised to find myself happily telling the emergency room that I would assess the patient shortly. The kids were horsing around on the playground, and I knew I would have to call my wife and ask her to come home. It would be my second forty five minute trip to the hospital on an otherwise busy Saturday afternoon.
For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, listened to the patient calmly, and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn't my life's work make me feel this way all the time?
I guess it starts with one simple fact. I blame myself: every heart attack, stroke, or new diagnosis of advanced cancer. As disturbing as it sounds, how could I not? It takes a certain type of personality to want to be a doctor. A kind of hyper conscientiousness pervades our wounded souls. What else would drive us to study while our cohorts play, or slave away in gross anatomy while our peers receive their first pay checks? And how does one wake up in residency after an hour of sleep with a foreboding sense of nausea and fatigue, and face an overwhelming twelve hour day of patient care?
You learn to believe that your actions matter, that your struggles draw the line between life and death. If you only work harder, stay up later, study more, bad things will cease to happen. This is the promise that drives us through these PTSD inducing situations. And, of course, the joy.
The joy in those fleeting moments where you hold a hand, sigh gently, and become one with the great swath of murky humanity. Those moments are what sustains us through the everyday torture that many of us signed up for eons in advance of the knowledge of what we would be doing.
Half of today's practicing physicians have been irreparably damaged by the experience, and huddle behind walls so impenetrable that patients can't break through their stone faced facade. The other half are trying so desperately to once again feel deeply, and yet not suffocate under the immense pressure of their daily lives.
If your are a patient, I suggest you avoid the former and seek out the latter.
If you are a medical student, you may want to learn how to embrace the joy now,
before it's too late.
For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, listened to the patient calmly, and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn't my life's work make me feel this way all the time?
I guess it starts with one simple fact. I blame myself: every heart attack, stroke, or new diagnosis of advanced cancer. As disturbing as it sounds, how could I not? It takes a certain type of personality to want to be a doctor. A kind of hyper conscientiousness pervades our wounded souls. What else would drive us to study while our cohorts play, or slave away in gross anatomy while our peers receive their first pay checks? And how does one wake up in residency after an hour of sleep with a foreboding sense of nausea and fatigue, and face an overwhelming twelve hour day of patient care?
You learn to believe that your actions matter, that your struggles draw the line between life and death. If you only work harder, stay up later, study more, bad things will cease to happen. This is the promise that drives us through these PTSD inducing situations. And, of course, the joy.
The joy in those fleeting moments where you hold a hand, sigh gently, and become one with the great swath of murky humanity. Those moments are what sustains us through the everyday torture that many of us signed up for eons in advance of the knowledge of what we would be doing.
Half of today's practicing physicians have been irreparably damaged by the experience, and huddle behind walls so impenetrable that patients can't break through their stone faced facade. The other half are trying so desperately to once again feel deeply, and yet not suffocate under the immense pressure of their daily lives.
If your are a patient, I suggest you avoid the former and seek out the latter.
If you are a medical student, you may want to learn how to embrace the joy now,
before it's too late.
Thursday, May 16, 2013
In Which I Respond To A Faithful Reader
Below find excerpts of an email sent by a faithful reader. I have included the whole text, but broken it down to respond to each point accordingly.
I have really enjoyed your blog postings and the sensitivity you showed toward patients. But, your new venture is a real turn off, and makes it hard for me to want to read your posts anymore.
I have been waiting for this. Expecting it. I knew that when I changed my practice model there would be anger and disappointment. For this reason, I have gone to the trouble of telling each patient face to face in the office when they come in for an appointment.
This has been my decision. I will own up to it. I won't hide behind a formal letter or slink out of the room. If patients are upset, I will soak in the anger and accept it. I owe that much.
So far I have received mostly understanding with a smattering of joy and disappointment. My patients know me very well, they don't believe I mean them harm.
My dear reader, sometimes you have to look eye to eye to see into some one's soul. A blog, unfortunately, does not allow for that.
As a patient (not yours), it seems like you are abandoning patients who do not have the money to pay your new fees for which you will take no insurance. Instead of staying in the trenches and finding the insurance battle with them, you seem to be washing your hands of it and leaving them on their own. Onward to people with disposable incomes to pay for handholding.
On the contrary, I'm still taking insurance. For fifty percent of my practice: nursing home, hospice, and palliative care there will be no extra charge. These are some of the most difficult and high risk patients. I will continue to stay in the trenches and battle for them.
I am changing, however, my outpatient primary care practice. I will charge a yearly fee along with billing insurance. The yearly fee pays for uncovered services like home care, cell phone access, and prolonged visits. I believe this is a fair trade off.
My perception may well be wrong. Perhaps I did not listen carefully enough to your explanations. I want to believe that you are who you appeared to be, a great, caring physician. But, I thought that you might like to know that at least one of your loyal blog followers doubts that now. Take care.
I would like to think that I am still perceived as a great, caring physician. I would also hope to be viewed as a strong patient advocate. But the problem is, I can't protect my patients from the ridiculous, pervasive stupidity of medicare and our modern day insurance Goliath.
I can keep bending, and giving, and finding ways to work around the vicious beast. Or, I can choose to step out of the lion's den. I will not be an enabler of this broken system.
Change will only come when doctors and patients alike are willing to stand up and say enough is enough.
I am in the unique position to do just that.
I have really enjoyed your blog postings and the sensitivity you showed toward patients. But, your new venture is a real turn off, and makes it hard for me to want to read your posts anymore.
I have been waiting for this. Expecting it. I knew that when I changed my practice model there would be anger and disappointment. For this reason, I have gone to the trouble of telling each patient face to face in the office when they come in for an appointment.
This has been my decision. I will own up to it. I won't hide behind a formal letter or slink out of the room. If patients are upset, I will soak in the anger and accept it. I owe that much.
So far I have received mostly understanding with a smattering of joy and disappointment. My patients know me very well, they don't believe I mean them harm.
My dear reader, sometimes you have to look eye to eye to see into some one's soul. A blog, unfortunately, does not allow for that.
As a patient (not yours), it seems like you are abandoning patients who do not have the money to pay your new fees for which you will take no insurance. Instead of staying in the trenches and finding the insurance battle with them, you seem to be washing your hands of it and leaving them on their own. Onward to people with disposable incomes to pay for handholding.
On the contrary, I'm still taking insurance. For fifty percent of my practice: nursing home, hospice, and palliative care there will be no extra charge. These are some of the most difficult and high risk patients. I will continue to stay in the trenches and battle for them.
I am changing, however, my outpatient primary care practice. I will charge a yearly fee along with billing insurance. The yearly fee pays for uncovered services like home care, cell phone access, and prolonged visits. I believe this is a fair trade off.
My perception may well be wrong. Perhaps I did not listen carefully enough to your explanations. I want to believe that you are who you appeared to be, a great, caring physician. But, I thought that you might like to know that at least one of your loyal blog followers doubts that now. Take care.
I would like to think that I am still perceived as a great, caring physician. I would also hope to be viewed as a strong patient advocate. But the problem is, I can't protect my patients from the ridiculous, pervasive stupidity of medicare and our modern day insurance Goliath.
I can keep bending, and giving, and finding ways to work around the vicious beast. Or, I can choose to step out of the lion's den. I will not be an enabler of this broken system.
Change will only come when doctors and patients alike are willing to stand up and say enough is enough.
I am in the unique position to do just that.
Tuesday, May 14, 2013
Practicing At The Top Of Your License
My son and daughter play violin. I accompany them to every class and stand over them in our living room as they practice. From the very beginning, the teachers required parental involvement. They often spent more time talking to me than my children. They instructed on posture and fingering. Eventually, I learned to read music. I even rented a violin of my own.
As the years have passed, I still play an active role. I know when my son's elbow rides too high or my daughter's wrist curves upward like when carrying a pizza. My ear can tell when a note is a touch too sharp or completely wrong. But as an adult, I find I have little time to practice the same hours as my offspring.
I returned the rented violin after months because it sat unused in the corner.
My children have far surpassed my abilities. Although I have knowledge of the appropriate technique and have learned the series of notes, I am a victim of insufficient practice. And indeed, one can look down the line from less to more experienced and realize the difference repetition makes. Although the notes are the same, the depth and quality of the sound that reverberates through the violin can be very different.
Only when one practices hour after hour, year after year, can the shadowy mirage of mastery shimmer in the distance.
There are no shortcuts.
Not in violin,
and not in medicine.
As the years have passed, I still play an active role. I know when my son's elbow rides too high or my daughter's wrist curves upward like when carrying a pizza. My ear can tell when a note is a touch too sharp or completely wrong. But as an adult, I find I have little time to practice the same hours as my offspring.
I returned the rented violin after months because it sat unused in the corner.
My children have far surpassed my abilities. Although I have knowledge of the appropriate technique and have learned the series of notes, I am a victim of insufficient practice. And indeed, one can look down the line from less to more experienced and realize the difference repetition makes. Although the notes are the same, the depth and quality of the sound that reverberates through the violin can be very different.
Only when one practices hour after hour, year after year, can the shadowy mirage of mastery shimmer in the distance.
There are no shortcuts.
Not in violin,
and not in medicine.
Monday, May 13, 2013
Caring 2.0: #HCSM And The Rise Of The Empathic Physician
We have our rock stars. Our members in the healthcare social media realm who have elevated the conversation to new heights. Physicians are tweeting, blogging, and popping up on news shows across the country. We are using our singular voices to educate on vaccines, heart disease, and the quantified self movement. We are acting locally, but teaching globally. The promise of social media has amplified our voices and carried our message to the unwashed masses.
We once could affect the few thousand who passed through our office doors. We now can touch the lives of millions. This dichotomy, fulfilling our individual covenants as well as our debt to society as a whole, has proven a powerful draw. One only has to look at the conversations on twitter to realize that our ranks are swelling. Not only physicians, but nurses, pharmacists, patients and advocates are both teaching and learning.
We all win, patients and providers alike.
Yet in our exuberance to transform, we continue to neglect certain self evident truths. It's time to pivot. It's time to not only tell people what we know, but who we are. Knowledge has it's limits, but does caring?
I propose we move to a Caring 2.0 mindset. The days of unidirectional emotion emanating from patient and bouncing off stoic expressionless physician are gone. Like the Healthcare 2.0 movement, the elevation of caregiving requires a blurring of the line between teacher and student. I can see no better way forward than social media.
We are human. We suffer, triumph, and struggle with our own inner demons. As Louise Aronson said in her book A History of the Present Illness:
Doctors, you see, aren't so different from patients. Every day we hope someone will see past our elaborate and very impressive window display to the jumble of expired products weighing down the shelves and choking the aisles of our psyches.
It is in this imperfection that we realize our best version of ourselves,
that we become the doctors our patients really need.
We once could affect the few thousand who passed through our office doors. We now can touch the lives of millions. This dichotomy, fulfilling our individual covenants as well as our debt to society as a whole, has proven a powerful draw. One only has to look at the conversations on twitter to realize that our ranks are swelling. Not only physicians, but nurses, pharmacists, patients and advocates are both teaching and learning.
We all win, patients and providers alike.
Yet in our exuberance to transform, we continue to neglect certain self evident truths. It's time to pivot. It's time to not only tell people what we know, but who we are. Knowledge has it's limits, but does caring?
I propose we move to a Caring 2.0 mindset. The days of unidirectional emotion emanating from patient and bouncing off stoic expressionless physician are gone. Like the Healthcare 2.0 movement, the elevation of caregiving requires a blurring of the line between teacher and student. I can see no better way forward than social media.
We are human. We suffer, triumph, and struggle with our own inner demons. As Louise Aronson said in her book A History of the Present Illness:
Doctors, you see, aren't so different from patients. Every day we hope someone will see past our elaborate and very impressive window display to the jumble of expired products weighing down the shelves and choking the aisles of our psyches.
It is in this imperfection that we realize our best version of ourselves,
that we become the doctors our patients really need.
Friday, May 10, 2013
CrisisMD Launched Today
CrisisMD.com launched today!
Our goal is to provide healthcare coaching, translational services, and advocacy to those in the midst of a crisis. Below find the post that spurred this business venture. It appeared recently on kevinmd.com.
If Only The Patient Had An Advocate
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?
Our goal is to provide healthcare coaching, translational services, and advocacy to those in the midst of a crisis. Below find the post that spurred this business venture. It appeared recently on kevinmd.com.
If Only The Patient Had An Advocate
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?
Thursday, May 9, 2013
Poof!
It happened once before. I logged onto the computer on a particularly challenging day to find that my blog was gone. Just like that. After countless posts, telling stories, complaining and rejoicing...poof. I was on WordPress at the time. I called the help line and frantically explained the situation. Weeks later I got the data back, unformatted and imported to a new web address.
I was crushed. Not just about the loss of all that writing, but more because the conversation had stopped. The unidirectional talk that I had been having with myself and my readers came to a sudden unexpected end. And when it finally came back, the connection had severed.
For a long time there was silence.
My writing is now hosted on blogger. Four hundred and seventy six posts later, the self expression dwarfs that of it's forebearer. Yet, I have taken no actions to record or backup my posts. Like a game of Russian Roulette, I keep hitting the publish button in complete denial. I have no explanation why I am paralyzed in taking such precautionary measures.
Poof!
Many have told me to collate my posts into a book. They say to self publish or get an agent. I have contemplated many times. But I could no more anthologize than I could backup my blog. We don't record our conversations with our friends, our loved ones. We remember them.
And this, my friend, is my conversation with you. I spew forth the randomness and you sometimes respond. You comment, email, or retweet. We have a relationship, real or imagined, I can't always tell.
I guess it was never really about the specific words.
I was just trying to tell you things.
I was crushed. Not just about the loss of all that writing, but more because the conversation had stopped. The unidirectional talk that I had been having with myself and my readers came to a sudden unexpected end. And when it finally came back, the connection had severed.
For a long time there was silence.
My writing is now hosted on blogger. Four hundred and seventy six posts later, the self expression dwarfs that of it's forebearer. Yet, I have taken no actions to record or backup my posts. Like a game of Russian Roulette, I keep hitting the publish button in complete denial. I have no explanation why I am paralyzed in taking such precautionary measures.
Poof!
Many have told me to collate my posts into a book. They say to self publish or get an agent. I have contemplated many times. But I could no more anthologize than I could backup my blog. We don't record our conversations with our friends, our loved ones. We remember them.
And this, my friend, is my conversation with you. I spew forth the randomness and you sometimes respond. You comment, email, or retweet. We have a relationship, real or imagined, I can't always tell.
I guess it was never really about the specific words.
I was just trying to tell you things.
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