Happy Birthday To Me

The guy hobbling into my office was literally a lifetime ahead of me. On the day of our visit, he was turning eighty and I forty. We shared a birthday. Things started as usual, an exchange of pleasantries and and then on to medical issues. What really concerned him that day, however, was his son. He still hadn't got married yet. Then there was his garden, his tomatoes were over watered.

We chatted easily as I finished my exam. His blood pressure was stable and his diabetes was controlled with diet only. I pushed my computer to the side and took a long look at him. He was exactly what most of us strived to be. Healthy and active,he was tackling his eighth decade with grace and beauty. I paused at my own reticence in leaving the thirties behind. It was a big day for both of us. Then I asked the question that had been on my mind about myself since waking up that morning (just change the number.)

So how does it feel to be eighty?

He smiled before answering. I sensed both pride and melancholy.

I still wake up every morning with the sweet taste of dreams on my tongue and a new plan for each day.

We both chuckled before I replied.

Ya, me too!

Are We Legislating A Primary Care Crisis?

It was the same years ago in residency. There was both a categorical and primary care residency track. Each had their own distinctive curriculum and rotation schedule. The outpatient track did more time in the clinic, the categorical more on the hospital wards. We trained side by side. We attended many of the same lectures. And our fellowship choices matched identically. In fact, most of my colleagues from the primary care group are now cardiologists, gastroenterologists, and pulmonologists. Even then, those in training changed their opinion midstream when they realized what their professional lives would entail.

It has become vogue to blame doctors and academic institutions for the falling number of generalists. We wag our fingers at the university behemoth who takes government moneys and then trains super specialized physicians. But, if you have been in education long enough, you know that the primary care push has been going on for decades. It just hasn't been that successful. Students and young physicians, time and again, change paths when faced with the day to day work of comprehensive primary care even though it is one of the most challenging and fulfilling jobs in medicine.

Indeed, one might say we have come here by our own careful planning. We have legislated it that way.

When you create a body that advises medicare on payment structure which is made largely of specialists and proceduralists and has no interest in protecting cognitive medicine,

You have legislated a primary care crisis.

When you create electronic medical records and define how to use them meaningfully, pushing physicians to waste their precious little time in the exam room on data entry,

You have legislated a primary care crisis.

When you pass a colossal healthcare reform package heavy on regulation and reporting, most of which falls on the lowly family physician toiling in the overcrowded office,

You have legislated a primary care crisis.

When you fight fraud and over billing of the few, by committing the many to ornate and easily deniable paperwork that everyone but the primary care doctor refuses to fill out,

You have legislated a primary care crisis.

When you tell hard working and well trained physicians that they can no longer go to the hospital, create inconceivable amounts of paperwork for those who do, and then try to replace them in their offices with nurse practitioners and physician assistants,

You have legislated a primary care crisis.

And lastly, when you tell them to abandon the doctor-patient dyad, and become team leaders in charge of administratively managing groups of non physician providers and turn them into community health gurus,

You have legislated a primary care crisis.

Doctoring Requires A Loss Of Freedom

It hit me all the sudden.  The feeling of calm washed over my body as I relaxed my torso and let my legs stretch forward in the passenger's seat.  My wife was driving and the kids were in the back.  I had just signed out, and taken off my pager for the holiday weekend.  I knew the feeling was false.  The phone calls would eventually come whether I was covering or not.  And they did.  The nursing home was a responsibility that was mine only.

Freedom.

I can't imagine someone outside of medicine understanding this empirically.  The act of doctoring requires a certain loss of freedom.  When we open our doors to those who seek us, we close our lives to restfulness.  Gone are the lazy days in the backyard hammock without a care in the world. 

Yep, I said it.  Taking care of people is a burden.  A wonderful calling and a privilege, but a burden none the less.  And one of the consequences of taking on this great privilege is that you will never quite escape the covenant which you have signed up to fulfill. 

Weekends, holidays, vacations, they have all been interrupted by unexpected emergencies.  I accept this responsibility and have long ago forgotten how to lament the loss of placidity.

But sometimes, for a moment, I forget.  My mind a drift on the hope that comes with an uncommon day of rest in the middle of the week, I escape the beloved chains of the endeavor I have dedicated my life to.

It usually lasts for about a moment,

before my mobile rings and pulls me back to reality.

What Would Osler Say?

There is a certain feeling of disenfranchisement among those of us who were present during the infancy of healthcare social media.  Before the days of twitter, the players were few, the interactions meaningful, and the main mechanism of change was a quaint self publishing tool called a weblog. 

We were out to rule the world. Blogs were well written and lengthy.  The expectation was that the comment section would be just as lively as the post itself.  There were no book deals, TED talks, or media interviews.  We were a group of whipper-snappers, bucking the system, and blazing the trail.

The advent of twitter and facebook brought welcome improvements.  Our opinions were amplified.  Our numbers grew.  And amazingly enough, the rest of the world took notice.  We were no longer just a group of disgruntled docs.  Patients, advocates, and allied healthcare professionals also joined our ranks. 

The winds of change, however, are indifferent to mourning for the past.  Our sacred space became cluttered not only with content, but also self promotion.  Blogs became shorter and to the point.  Comments were slung at each other in small word size tidbits that often lost the subtlety of artful communication.  The noise became at times unbearable. 

We see this same type of change happening in the practice of clinical medicine.  We use terms like "creative destruction" and "disruptive innovation" to describe what medical futurists must see as the brave new world of healthcare delivery.  But I fear that we run the risk of throwing the baby out with the bath water.  In other words, quantified self, big data, accountable care organizations, and the electronic revolution must seek to add and not replace our current infrastructure. 

In both medicine and social media, it would be complete and utter foolishness to actually destroy that which was built with the blood and sweat of our forebearers.

I would like to think that today's healthcare social media giants climbed on our backs not to push us down, but rather to reach better more lucid heights. 


I'm sure if Osler was around today, he would say much the same thing.

Life's Complications

I was preoccupied.  My mind leaped between worrying about the success of my new practice and the deathly ill young man in the ICU.  I still hadn't gotten to that blog post I had been meaning to write. I was so far into the clouds that I barely noticed them rumble.  The helmeted kids were ahead of us on their bikes, pedaling away.  My wife and I had just rounded the corner of our leisurely walk.  We were making the trip back home.

The crash above us was getting closer.  My wife turned toward the menacing clouds on the horizon, and then shouted in the direction of the kids.

Run!

I instinctively put my hand to my pocket to protect the mobile phone and sprinted forward.  As if on cue, the first rain drop plopped on my prematurely balding scalp.  The avalanche of water came quickly.  We ran past the kids who were giggling and pumping their legs for maximal speed.  My shirt clung to my chest, waterlogged.

The torrent engulfed us.  The tension between my shoulders began to relax, and all the muscles of my body gave a collective sigh.  I raised my head to the sky and opened my mouth.  We were almost home. 

We crashed through the door and crumpled to the ground.  And laughed.  And laughed, and laughed.

Husband and wife, son and daughter. 

Through the tangled stress of my complicated life, the world brought me back to silly, old fashioned, often forgotten,

joy.

Nothing Has Changed, Everything Has Changed

It was both monumental and banal at the same time.

I sat at the restaurant with the check stowed safely in my right pant pocket.  The flimsy piece of paper burned through the cloth and singed the hair on my thigh.  It was screaming for attention,  trying to distract from the conversation and deliver me back to the worried thoughts that filled my mind over the last few weeks.  Will they come, will they come?

After breakfast, the whole family got back into the car and drove towards the bank.  They waited in the parking lot as I leaped towards the front door.  I had already filled out the deposit slip.  The line for the teller was short.  I handed the check and the slip forward and waited for something to happen.  Would thunder crash through the sky and lightning blaze down past the roof and strike me on the spot?  With little fanfare, she handed me a receipt, and I was returning to the car.

Nothing has changed, everything has changed.

With the deposit of my first check, I have started the true transition into my new practice.  Some may call it concierge, others membership based.  But what the lawyers tell me is that I am now charging for uncovered services.  There is much uncertainty.  Only after hearing my colleagues reactions have I started to question myself.  They hem and haw as they tell me that I am bold.  They envy my willingness to take such a risk.

For me, however, the risk is in staying the same.  The risk is abandoning one's beliefs to join the great healthcare race to assimilation.  Physicians will change their ways.  The art of medicine will become a borg like delivery of cookbook solutions spoken in hushed tones and explained in reams of computer printouts. 

Did you get the after visit summary, what about the patient education materials?

Will they come or not?  I have no idea. 

I am scared.  I have placed a value on my abilities, and now must wait to see if my patients are in agreement. 

What I don't question is the certainty of the stand I am taking.  Today, I stepped out of the system.  I abandoned the structure that has been placed on me since the day I accepted the position in my medical school class.

This has not been easy and comes with a great deal of risk . 

I will do it anyway.

I have done it already.

Demand Apathy

Monday afternoons are always the same.  I pick up the kids from their grandparents.  We drive home with their backpacks and a carton of home made food.  We park in the garage, and carry all the contents of the car into the house.  As the kids unload, I push the recycle container to the front for street pickup the next day. 

Occasionally, I stop and socialize.  Yesterday, I waited at the edge of the sidewalk as a neighbor approached.  A young healthy fellow, I was surprised to see his posture stooped and his head bent forward.  Apparently he was under the weather.  He had a slew of symptoms: fevers, chills, and a sore back. 

I enquired about his recent doctors visit.  His physician was top rate, I had suggested him myself.  But that's when my neighbor's face became particularly animated.  His visit  the week before had ended in blood tests and an Xray.  But seven days later, no results.  In fact, several calls over the last forty eight hours had been left unanswered. 

I shook my head, and watched him stumble into his house.  I knew his doctor to be of high quality, but ever since he had been bought by the local hospital, the number of complaints had risen.  It was a common issue.  A few patients each week were showing up at my doorstep because they felt like the practice they had been going to for years no longer cared for them. 

I would like to believe that this was only happening in the big medical groups, but I have heard the same among private practices also.  And sadly, I feel fairly certain that I know why.

In the old world, physicians answered only to one master: the patient.  In the new world order, patients are becoming a lowly voice in the crowd of entities shouting at physicians.  There is a kind of demand apathy.  After tending to the insurance companies, the government, the hospital, the medical group administrators, and the electronic medical record, your physician may or may not have time to address your needs.

We talk of the devastation of physician suicide.  We lament as more and more doctors bow out of clinical practice.  But on a larger scale, what may be most harmful to the American populace is the great apathy that is sprouting in this once proud profession.

My neighbor will eventually get better.  The virus attacking his system will abate.  The inflammation will resolve.

His trust in the system, however, has suffered a mortal blow.