When I say it's a privilege I see your eyes go cross. You think I'm daft. You reason that you are to young too talk about such things, or old but healthy, or that the cancer has spread but you want to remain optimistic. And I shake my head and think of my father.
He never had the luxury.
At the age of forty, he left early one morning to round at the hospital and never came back. A small blood vessel burst in his brain causing irreparable havoc. By the time we arrived, he was connected to all the appropriate machines. Back then, there was no talk of such things as preexisting wishes. The neurosurgeon, my father's colleague, told us he was gone and the ventilator was removed. His body quickly caught up with his severely damaged brain. He died.
You see, my father passed way before he was afforded the privilege we are discussing today; the privilege of seeing death as a shimmery mirage somewhere in the distant future.
The privilege of having a modicum of control over that which you fear the most is a gift. I humbly offer this to you.
Please take some time to think about your code status and advanced directives.
Saturday, October 5, 2013
Thursday, October 3, 2013
IRL
(This would be the start of a great #hcsm joke)
@hjluks walks into the lobby of a posh New York athletic club. I am sitting by the elevators. While he approches, I marvel at how easily I recognize him. It's not that he looks so much like his twitter avatar, I just feel like I've met him before. We shake hands and embrace.
The conversation begins as if we we starting where we left off last time. But there was no last time. We exchange pleasantries and go right to substance. I look over at the elevator bank wondering if we should go up to the conference room, or just stand in the walkway. And talk forever.
Eventually we make our way to the tenth floor. Over bagels and fruit we welcome each participant as they arrive. Some of us have met before, others have not. Our content, however, belays a sense of commonality. We may be diverse in experience and profession, but we share certain ties.
The meeting has it's ebb and flow. I am beginning to form archetypes in my mind of the participants. To my right is @dlschermd. He lends me his marker from time to time (mine is barely functional).
@dlschermd reminds me of the brilliant professor that we all had in college, but better. He's neither bumbling nor arrogant. His generosity of thought far outweighs his freedom with writing utensils. Measured and insightful, the room becomes silent when he speaks.
Across from me sits @joshuaschwimmer. I can feels his gaze upon me when I speak. He is concentrating, dissecting. When he raises his voice to reply, I am completely sure that the first sentence will have the word "app" in it. And I'm right, but what comes next is often brilliant and throws my opinions completely on their side. Sometimes he says something and I think he is completely off base, till I realize that he is about ten steps ahead of me and I hadn't thought it out completely yet.
@PhilBaumann is calm and collected. He forgives me multiple times for interrupting without so much as making a grimace. He waits until there is a lull in the conversation and then proceeds forward. Although I have no basis for my opinion, I get the feeling that below the surface there is a ferocity. Controlled, tamed, but deadly when necessary. I wouldn't want to be on the wrong side of a heated argument with him.
Through @nickdawson (and @PhilBaumann)I can feel the patient advocacy shine through. @nickdawson is one of those rare people who speaks of ACOs and value based purchasing not with the grime of consumerism dripping from his lips, but with a zeal for providing more services for less cost for those in need. He later told me that as a hospital administrator he would sit in various places in his facility with a laptop and observe. I bet no one ever asked him to do this.
@hjluks sits towards the front. Calm. Engaged. He talks exactly the way he blogs. Disparate ideas become cohesive thoughts, wrapped in a bow and presented to us in such orderly fashion that one wonders if the problems of the world are really so unsolvable.
And all these fine gentleman tolerate my verbose and often repetitive opinions. They are confident in who they are.
The meeting ends and I lament that I have to say goodbye to Howard, David, Joshua, Phil, and Nick. It's been such a gratifying conversation.
I'm hoping I'll be lucky enough to get to drop the @ sign again soon.
@hjluks walks into the lobby of a posh New York athletic club. I am sitting by the elevators. While he approches, I marvel at how easily I recognize him. It's not that he looks so much like his twitter avatar, I just feel like I've met him before. We shake hands and embrace.
The conversation begins as if we we starting where we left off last time. But there was no last time. We exchange pleasantries and go right to substance. I look over at the elevator bank wondering if we should go up to the conference room, or just stand in the walkway. And talk forever.
Eventually we make our way to the tenth floor. Over bagels and fruit we welcome each participant as they arrive. Some of us have met before, others have not. Our content, however, belays a sense of commonality. We may be diverse in experience and profession, but we share certain ties.
The meeting has it's ebb and flow. I am beginning to form archetypes in my mind of the participants. To my right is @dlschermd. He lends me his marker from time to time (mine is barely functional).
@dlschermd reminds me of the brilliant professor that we all had in college, but better. He's neither bumbling nor arrogant. His generosity of thought far outweighs his freedom with writing utensils. Measured and insightful, the room becomes silent when he speaks.
Across from me sits @joshuaschwimmer. I can feels his gaze upon me when I speak. He is concentrating, dissecting. When he raises his voice to reply, I am completely sure that the first sentence will have the word "app" in it. And I'm right, but what comes next is often brilliant and throws my opinions completely on their side. Sometimes he says something and I think he is completely off base, till I realize that he is about ten steps ahead of me and I hadn't thought it out completely yet.
@PhilBaumann is calm and collected. He forgives me multiple times for interrupting without so much as making a grimace. He waits until there is a lull in the conversation and then proceeds forward. Although I have no basis for my opinion, I get the feeling that below the surface there is a ferocity. Controlled, tamed, but deadly when necessary. I wouldn't want to be on the wrong side of a heated argument with him.
Through @nickdawson (and @PhilBaumann)I can feel the patient advocacy shine through. @nickdawson is one of those rare people who speaks of ACOs and value based purchasing not with the grime of consumerism dripping from his lips, but with a zeal for providing more services for less cost for those in need. He later told me that as a hospital administrator he would sit in various places in his facility with a laptop and observe. I bet no one ever asked him to do this.
@hjluks sits towards the front. Calm. Engaged. He talks exactly the way he blogs. Disparate ideas become cohesive thoughts, wrapped in a bow and presented to us in such orderly fashion that one wonders if the problems of the world are really so unsolvable.
And all these fine gentleman tolerate my verbose and often repetitive opinions. They are confident in who they are.
The meeting ends and I lament that I have to say goodbye to Howard, David, Joshua, Phil, and Nick. It's been such a gratifying conversation.
I'm hoping I'll be lucky enough to get to drop the @ sign again soon.
Tuesday, October 1, 2013
There Is No I In Team
I was spiking a fever.
It was as if someone flipped a light switch inside my body. I could feel the sensation rise through the chest, and trample the dazed contents of my skull. Light, however, was a poor, lazy metaphor. There was no heat, only stimulation.
My belly ached from the repetitive heaving that preceded the fever. I envisioned the sandwich I had eaten that afternoon. I pictured small bacteria crowding into the generous dollop of mayonnaise wantonly placed by the store clerk. It was food poisoning. I was sure of it.
I cautiously sipped from the glass of water on the bedside table. My mouth, parched and yearning, was ignoring the revulsion in my mid section. I celebrated the brief ecstasy of quenching the abominable thirst before my belly began to swirl. I got up and ran to the bathroom.
Collapsing back in bed, I looked glassy eyed at my mobile phone which had just begun to ring. I mustered my strength, and picked it up.
Dr. G, It's Lisa at the nursing home, Mr. W's pain is out of control again. I tried the five of roxanol with little effect. His family is getting anxious!
I took a deep breath, and gave a few orders. I then fell back into bed. I had a long night ahead of me.
In fact, my sleepless night came at the end of a long weekend. Not being on call, my family and I treated ourselves to a few days in the city. We swam, we rode bikes, we deserted at Ghiradelli's. Carefree fun in the sun, right?
Well, not exactly. My hour long bike ride was interrupted by three phone calls. While swimming, I had to keep my mobile close in a dry and safe place. And even a hot fudge Sunday couldn't be eaten without some medical question or another needing to be answered. All of this, on my weekend off.
It has become popular to describe my breed of physician as outdated; to say that we have a hero complex, and can't adapt to today's team based mentality. If we would just loosen the reins and hand off some of the responsibility. Groups think better than individuals!
Unfortunately, I have found it all but impossible to "hand off" large numbers of debilitated nursing home patients. The care is too complex, too involved. On the aforementioned weekend, during my little vacation, I had a patient die (expected), and another develop multiple pulmonary emboli. Not to mention the diagnosis and treatment of a slew of new infections as well as a minor fracture.
All of this was managed in the nursing home, with close coordination between staff and families.
When physicians unfamiliar with these kind of patients try to cover, bad things happen. Hospice patients get sent to the emergency room. Demented people get inappropriately put on antibiotics for nonexistent urinary tract infections. The quality of care goes down.
So when I get sick, or take a weekend off, you better believe that I am going to answer that phone call. Because many of those patients are suffering far worse than I. It's not that I am trying to be a hero.
I'm hoping to become the kind of physician that I would want to care for my loved ones.
It was as if someone flipped a light switch inside my body. I could feel the sensation rise through the chest, and trample the dazed contents of my skull. Light, however, was a poor, lazy metaphor. There was no heat, only stimulation.
My belly ached from the repetitive heaving that preceded the fever. I envisioned the sandwich I had eaten that afternoon. I pictured small bacteria crowding into the generous dollop of mayonnaise wantonly placed by the store clerk. It was food poisoning. I was sure of it.
I cautiously sipped from the glass of water on the bedside table. My mouth, parched and yearning, was ignoring the revulsion in my mid section. I celebrated the brief ecstasy of quenching the abominable thirst before my belly began to swirl. I got up and ran to the bathroom.
Collapsing back in bed, I looked glassy eyed at my mobile phone which had just begun to ring. I mustered my strength, and picked it up.
Dr. G, It's Lisa at the nursing home, Mr. W's pain is out of control again. I tried the five of roxanol with little effect. His family is getting anxious!
I took a deep breath, and gave a few orders. I then fell back into bed. I had a long night ahead of me.
In fact, my sleepless night came at the end of a long weekend. Not being on call, my family and I treated ourselves to a few days in the city. We swam, we rode bikes, we deserted at Ghiradelli's. Carefree fun in the sun, right?
Well, not exactly. My hour long bike ride was interrupted by three phone calls. While swimming, I had to keep my mobile close in a dry and safe place. And even a hot fudge Sunday couldn't be eaten without some medical question or another needing to be answered. All of this, on my weekend off.
It has become popular to describe my breed of physician as outdated; to say that we have a hero complex, and can't adapt to today's team based mentality. If we would just loosen the reins and hand off some of the responsibility. Groups think better than individuals!
Unfortunately, I have found it all but impossible to "hand off" large numbers of debilitated nursing home patients. The care is too complex, too involved. On the aforementioned weekend, during my little vacation, I had a patient die (expected), and another develop multiple pulmonary emboli. Not to mention the diagnosis and treatment of a slew of new infections as well as a minor fracture.
All of this was managed in the nursing home, with close coordination between staff and families.
When physicians unfamiliar with these kind of patients try to cover, bad things happen. Hospice patients get sent to the emergency room. Demented people get inappropriately put on antibiotics for nonexistent urinary tract infections. The quality of care goes down.
So when I get sick, or take a weekend off, you better believe that I am going to answer that phone call. Because many of those patients are suffering far worse than I. It's not that I am trying to be a hero.
I'm hoping to become the kind of physician that I would want to care for my loved ones.
Saturday, September 28, 2013
Are You Listening?
He was an expert in healthcare policy. He wrote nationally lauded papers on such things as evidence based medicine. He spent half his time in Washington advising one governmental agency or another, the other tucked away quietly at the VA. Originally he attended at the University, but that didn't last long.
We residents avoided him at all costs. Not only did he piss away our precious time with verbose and often tangentially related lectures, he was down right dangerous. The head of internal medicine knew it; our chief resident knew it. So schedules were shuffled, teams were adjusted. Often the strongest housestaff were pulled to work on his team, and clean up the mess he made.
Years later, I now realize, that a number of poor unsuspecting veterans likely suffered by his clumsy hands. Thankfully, someone of authority usually stepped in before irreversible damage occurred. It was not that he didn't understand pathophysiology or differential diagnosis. His deficit was far more worrisome, he completely lacked in the art of medicine. When a patient zigged, he zagged. He flawlessly applied inappropriate and poorly timed algorithms in a rigid and ineffectual manner.
And worst of all, buoyed by all the back patting in Washington, he was utterly confident in his abilities.
Occasionally I still hear about him from time to time. Prancing through political circles or spouting off on CNN. His smile is wide and confident, but I will always remember his frown as a patient circled the drain, a victim of his misapplied "science".
And I shudder, shudder to think that the politicians who currently shape our healthcare policy are listening to him intently.
We residents avoided him at all costs. Not only did he piss away our precious time with verbose and often tangentially related lectures, he was down right dangerous. The head of internal medicine knew it; our chief resident knew it. So schedules were shuffled, teams were adjusted. Often the strongest housestaff were pulled to work on his team, and clean up the mess he made.
Years later, I now realize, that a number of poor unsuspecting veterans likely suffered by his clumsy hands. Thankfully, someone of authority usually stepped in before irreversible damage occurred. It was not that he didn't understand pathophysiology or differential diagnosis. His deficit was far more worrisome, he completely lacked in the art of medicine. When a patient zigged, he zagged. He flawlessly applied inappropriate and poorly timed algorithms in a rigid and ineffectual manner.
And worst of all, buoyed by all the back patting in Washington, he was utterly confident in his abilities.
Occasionally I still hear about him from time to time. Prancing through political circles or spouting off on CNN. His smile is wide and confident, but I will always remember his frown as a patient circled the drain, a victim of his misapplied "science".
And I shudder, shudder to think that the politicians who currently shape our healthcare policy are listening to him intently.
Tuesday, September 24, 2013
I Call Bullshit
I am hard on myself. I'm the first one to point the finger inward. Every patient that dies, every adverse outcome, I study my decisions in excruciating detail. I have high standards. I don't sugar-coat the abilities of myself or my colleagues.
As the owner of my own medical practice, director of a nursing home, expert witness, and associate director for a hospice and palliative care company, I have vast experience dealing with the pitfalls of our medical system. After seeing thousands of patients, in almost every setting over the last seventeen years, I strongly question what I have been recently reading on my twitter feed.
According to a new study in The Journal of Patient Safety, preventable adverse events (PAEs) account for over 440,000 deaths a year in hospitals making medical error the third leading cause of mortality in the United States.
I call bullshit!
In my experience patients die of metastatic cancer, end stage dementia, coronary artery disease, stroke, and sepsis. Of the thousands of patients I have watched die, only a handful, at most, were complicated by preventable adverse events. And most of these happened in patients with highly involved, already terminal diseases, where the pure number of physicians and treatments multiplied the complexity.
I'm not saying that medical error doesn't occur. I'm not saying that we shouldn't have a robust bevy of researchers and experts studying the issue. None of us should rest knowing that our patients lives are at risk.
But I have to think that the extrapolations that led to this data set are faulty.
It just doesn't match what most of us are seeing in the trenches.
As the owner of my own medical practice, director of a nursing home, expert witness, and associate director for a hospice and palliative care company, I have vast experience dealing with the pitfalls of our medical system. After seeing thousands of patients, in almost every setting over the last seventeen years, I strongly question what I have been recently reading on my twitter feed.
According to a new study in The Journal of Patient Safety, preventable adverse events (PAEs) account for over 440,000 deaths a year in hospitals making medical error the third leading cause of mortality in the United States.
I call bullshit!
In my experience patients die of metastatic cancer, end stage dementia, coronary artery disease, stroke, and sepsis. Of the thousands of patients I have watched die, only a handful, at most, were complicated by preventable adverse events. And most of these happened in patients with highly involved, already terminal diseases, where the pure number of physicians and treatments multiplied the complexity.
I'm not saying that medical error doesn't occur. I'm not saying that we shouldn't have a robust bevy of researchers and experts studying the issue. None of us should rest knowing that our patients lives are at risk.
But I have to think that the extrapolations that led to this data set are faulty.
It just doesn't match what most of us are seeing in the trenches.
Sunday, September 22, 2013
Death Is A Period Occuring At The End Of A Sentence
You are dying.
I have reviewed the Cat Scans, spoken to the specialists, and studied the labs. There are many possible treatments that could be offered, but I fear they will not stem the course of all that is happening already. The tumor is too advanced, the metastases, too malignant.
I know there are many questions about chemotherapy, radiation, and feeding tubes. I would caution you to think of death as the inevitable endpoint. There are many things we can do between now and that endpoint. Some will increase your life expectancy, and some will cause pain and discomfort. The trick is to decide what is more important to you: quantity vs quality. Many life prolonging treatments come at a price. Chemotherapy causes nausea and fatigue. Radiation has many untoward effects. Feeding tubes get infected and accidentally pulled out.
You must feel like all hope is gone. But I want you to know that I have great hope. Let me explain. In my experience every person, young and old, healthy and diseased, wakes up each morning with a plan for the day. Although sometimes those plans are unreachable (you will not be able to make that last trip to Florida), others are quite possible. You should expect to spend each day with your pain controlled and in a safe environs. My goal is for you to experience pleasure, no matter how small. This, I can do for you.
I do not know when you are going to die. Doctors are poor at estimating such things. But I would like to help you focus on the life each day occurring around you. Death is a period at the end of a sentence, not a parenthesis or quotation mark.
Although my role in "curing" is over, I will by no means abandon you. In fact, I will be even more engaged. You need me more now than you did when I was treating your high blood pressure and colds. We will travel this road together.
And on the day when death finally comes. You will be cared for, likely pain free,
And surrounded by love.
I have reviewed the Cat Scans, spoken to the specialists, and studied the labs. There are many possible treatments that could be offered, but I fear they will not stem the course of all that is happening already. The tumor is too advanced, the metastases, too malignant.
I know there are many questions about chemotherapy, radiation, and feeding tubes. I would caution you to think of death as the inevitable endpoint. There are many things we can do between now and that endpoint. Some will increase your life expectancy, and some will cause pain and discomfort. The trick is to decide what is more important to you: quantity vs quality. Many life prolonging treatments come at a price. Chemotherapy causes nausea and fatigue. Radiation has many untoward effects. Feeding tubes get infected and accidentally pulled out.
You must feel like all hope is gone. But I want you to know that I have great hope. Let me explain. In my experience every person, young and old, healthy and diseased, wakes up each morning with a plan for the day. Although sometimes those plans are unreachable (you will not be able to make that last trip to Florida), others are quite possible. You should expect to spend each day with your pain controlled and in a safe environs. My goal is for you to experience pleasure, no matter how small. This, I can do for you.
I do not know when you are going to die. Doctors are poor at estimating such things. But I would like to help you focus on the life each day occurring around you. Death is a period at the end of a sentence, not a parenthesis or quotation mark.
Although my role in "curing" is over, I will by no means abandon you. In fact, I will be even more engaged. You need me more now than you did when I was treating your high blood pressure and colds. We will travel this road together.
And on the day when death finally comes. You will be cared for, likely pain free,
And surrounded by love.
Wednesday, September 18, 2013
Buyer Beware
Gertrude wasn't able tell me herself. She was ninety years old and moderately demented. It was her daughter who called. She pleasantly greeted me as I picked up the phone.
We had a good working relationship, Gertrude's daughter and I. We navigated a heart attack and stroke, multiple hospitalizations, and many discussions concerning end of life care. Gertrude was well taken care of. She was lucky enough to have a group of helpers who were under the doting, watchful eyes of her daughter.
In fact, the last pneumonia and urinary tract infection were both treated successfully at home without need for hospitalization. I guess I took it for granted that Gertrude would be a part of my new practice. I had no doubt she could afford it. So I assumed that this would be a phone call about some pressing issue or another.
But I was wrong.
Gertrude's daughter called to thank me for my service, and inform me that her mother was moving to another office. Her voice was smooth and confident with a tinge of pride as she gushed about the first visit that occurred earlier that morning. Although saddened by the realization that I would never see Gertrude's warm if not vacant smile, I tried my best to be gracious. I offered to have my staff forward the medical records, and wished them well.
A few days later, I received a letter from Gertrude's new doctor. He thanked me for the referral, and enclosed a copy of his note. My hands started to shake as I read the assessment and plan.
Gertrude, my ninety year old demented woman, was referred for a screening mammogram and a colonoscopy. To add injury to insult, he ordered full lab work including a cholesterol panel.
No matter how depressed I am at this unbelievably inappropriate care, I can't complain. It was I who changed things up on Gertrude. I have no right to be indignant. But I would like to offer a word of warning for all those out there looking for new doctors.
Buyer Beware!
You can no longer be a passive force in your own medical care. Before you race into the bosom of a new provider, do the research. After each visit, question each new prescription and lab order.
And above all else,
Verify. Verify. Verify.
We had a good working relationship, Gertrude's daughter and I. We navigated a heart attack and stroke, multiple hospitalizations, and many discussions concerning end of life care. Gertrude was well taken care of. She was lucky enough to have a group of helpers who were under the doting, watchful eyes of her daughter.
In fact, the last pneumonia and urinary tract infection were both treated successfully at home without need for hospitalization. I guess I took it for granted that Gertrude would be a part of my new practice. I had no doubt she could afford it. So I assumed that this would be a phone call about some pressing issue or another.
But I was wrong.
Gertrude's daughter called to thank me for my service, and inform me that her mother was moving to another office. Her voice was smooth and confident with a tinge of pride as she gushed about the first visit that occurred earlier that morning. Although saddened by the realization that I would never see Gertrude's warm if not vacant smile, I tried my best to be gracious. I offered to have my staff forward the medical records, and wished them well.
A few days later, I received a letter from Gertrude's new doctor. He thanked me for the referral, and enclosed a copy of his note. My hands started to shake as I read the assessment and plan.
Gertrude, my ninety year old demented woman, was referred for a screening mammogram and a colonoscopy. To add injury to insult, he ordered full lab work including a cholesterol panel.
No matter how depressed I am at this unbelievably inappropriate care, I can't complain. It was I who changed things up on Gertrude. I have no right to be indignant. But I would like to offer a word of warning for all those out there looking for new doctors.
Buyer Beware!
You can no longer be a passive force in your own medical care. Before you race into the bosom of a new provider, do the research. After each visit, question each new prescription and lab order.
And above all else,
Verify. Verify. Verify.
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