We were pretty damn lucky that she was young and healthy.
The surgery had been technically successful. I watched as the resident finished with the last sutures. Although the attending had already left the room, I looked on with the eagerness of a third year student. Orders were written, and the patient was transferred to recovery.
It was a routine hysterectomy. None of the pizazz and flare of a gyne onc surgery, but at such an early stage in my career, I thought I was witnessing rocket science. We left the OR and rounded for the rest of the afternoon. As I hunkered in for a long evening in the hospital, I got a page from the resident.
Our hysterectomy dropped her blood pressure, meet me in her room!
The seen was serene. Our patients blood pressure was low indeed, but she was none the worse for it. Her belly was tender, but not alarmingly so given her recent surgery. We checked the numbers again manually, adjusted the fluids, and sent stat labs. We had no idea how long of a night we were in for.
As the hours passed the blood pressure continued to drop after each bolus of fluid. Serial blood counts showed that the hemoglobin was dropping disturbingly. I ordered a few units of packed red blood cells and listened to the resident arguing with the attending.
She's bleeding out. We need to go back to the OR now!
The attending, however, was unconvinced. In a strange haze of denial, she came up with any and every reason not to take the patient to the operating table. And so the resident and I sat at the bedside all night adjusting IV's, ordering more transfusions, and praying.
The miracle came around five o'clock the next morning. The hypotension resolved. The counts stabilized. Large purplish bruises outlined the patients abdomen and back, a reminder of the huge amounts of blood that had been lost. The resident and I figured that the fussy bleeder must have finally tamponaded.
The attending rounded in her usual fashion. She entered the patients room with an air of confidence. She turned to the resident smugly and barked off a few orders. It was clear that she was patting herself on the back for what she believed had been the right decision.
Years later, I still find it surprising that our patient survived the night. I have no doubt that the right thing to do would have been to return to the OR immediately and address the hemorrhage surgically.
And this seems to be the problem with difficult, involved decisions. Sometimes the decision makers are vested emotionally and otherwise. Often our vision is clouded, even when the correct path of action is undeniably staring us in the face.
As the drumbeat of healthcare reform marches on, there are those physicians and policymakers who call for greater regulation and more reporting.
Physicians like myself, working in the trenches, find ourselves backed into a familiar corner.
Our patient lies in the bed hemorrhaging, and we stand close by with both hands tied behind our backs hoping upon hope,
for another unlikely miracle.
Saturday, July 20, 2013
Wednesday, July 17, 2013
Should Lawyers Be The New Doctors?
Dear patients,
It has been a hard week. I wanted to take a moment to personally apologize for all that you have endured. As one who has witnessed your pains and struggles, I can only wince with each new passing hurdle you are forced to leap over. This business of disease and illness is not for the weak of heart (metaphorically, that is).
To the man stranded in the hospital with a pelvic fracture, I wanted to say I'm sorry. Contrary to what you have been told, it was not I who gave the order to make your admission an observation. In fact, I did just the opposite. I had clicked the full admission order while doing the requisite computer work after seeing you that first night in the hospital. But the next day, I received a call from a physician in a distant city who has been paid by the medical center to review such cases. Although he reluctantly admitted that he is a pediatrician who doesn't even take care of adults, he has been given the power to interpret medicare rules and has decided that you don't qualify for inpatient status. Unfortunately it is of little interest to medicare, or this physician, that you are non ambulatory and that your wife is to frail to lift you. If you want to go to a skilled facility to strengthen before returning home, you'll have to pay for it yourself.
I'm sorry for the young woman I saw in the office crippled by pain caused by gastroesophageal reflux. I cannot explain why your insurance company has decided to deny my prescription for twice a day prilosec. I am aware that they have always filled it in the past. I am also aware that you have now been out of medication for a week, and are in severe discomfort. It baffles the human mind to understand the foibles of prescription coverage. It would be impossible for the insurance company to know, as I do, that you had been hospitalized with these symptoms and only by using the medicine twice a day have you found relief. This is a secret that only you and I share.
I'm sorry to the middle aged man who unexpectedly suffered a life altering stroke. Unable to walk, I had great hope that a motorized wheel chair would give you the mobility and Independence that had been cruelly taken from you. I filled out the paperwork as carefully as I knew how, but the request was denied. I know that the world is full of fraud and misuse, but surely even the most uneducated could see that you are a perfect candidate for such technology.
I guess I can only imagine the unendurable suffering to all of you caused by such indiscriminate shows of brute force by our medical system. I too suffer. Not, of course, like you. I ache from the depths of my being when the product of my life's work is sour and impotent. I spent all those years learning how to become a healer, a secretary and insurance negotiator I am not.
My skill set no longer matches your needs.
Perhaps a lawyer would get you farther.
It has been a hard week. I wanted to take a moment to personally apologize for all that you have endured. As one who has witnessed your pains and struggles, I can only wince with each new passing hurdle you are forced to leap over. This business of disease and illness is not for the weak of heart (metaphorically, that is).
To the man stranded in the hospital with a pelvic fracture, I wanted to say I'm sorry. Contrary to what you have been told, it was not I who gave the order to make your admission an observation. In fact, I did just the opposite. I had clicked the full admission order while doing the requisite computer work after seeing you that first night in the hospital. But the next day, I received a call from a physician in a distant city who has been paid by the medical center to review such cases. Although he reluctantly admitted that he is a pediatrician who doesn't even take care of adults, he has been given the power to interpret medicare rules and has decided that you don't qualify for inpatient status. Unfortunately it is of little interest to medicare, or this physician, that you are non ambulatory and that your wife is to frail to lift you. If you want to go to a skilled facility to strengthen before returning home, you'll have to pay for it yourself.
I'm sorry for the young woman I saw in the office crippled by pain caused by gastroesophageal reflux. I cannot explain why your insurance company has decided to deny my prescription for twice a day prilosec. I am aware that they have always filled it in the past. I am also aware that you have now been out of medication for a week, and are in severe discomfort. It baffles the human mind to understand the foibles of prescription coverage. It would be impossible for the insurance company to know, as I do, that you had been hospitalized with these symptoms and only by using the medicine twice a day have you found relief. This is a secret that only you and I share.
I'm sorry to the middle aged man who unexpectedly suffered a life altering stroke. Unable to walk, I had great hope that a motorized wheel chair would give you the mobility and Independence that had been cruelly taken from you. I filled out the paperwork as carefully as I knew how, but the request was denied. I know that the world is full of fraud and misuse, but surely even the most uneducated could see that you are a perfect candidate for such technology.
I guess I can only imagine the unendurable suffering to all of you caused by such indiscriminate shows of brute force by our medical system. I too suffer. Not, of course, like you. I ache from the depths of my being when the product of my life's work is sour and impotent. I spent all those years learning how to become a healer, a secretary and insurance negotiator I am not.
My skill set no longer matches your needs.
Perhaps a lawyer would get you farther.
Friday, July 12, 2013
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!
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!
Monday, July 8, 2013
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.
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.
Saturday, July 6, 2013
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.
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.
Sunday, June 30, 2013
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.
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.
Thursday, June 27, 2013
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.
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.
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