I'm Sounding The Death Knell

It was a particularly challenging case.  On the car ride into the hospital, I found myself doing something that I rarely do.  I called a local allergist for an inpatient consult.  Most allergy issues are not an emergency.  So it is odd indeed to summon this particular kind of physician into the medical wards.  His nurse took the message and promised that she would plug my mobile number into his pager.

A few minutes later we were discussing the particulars of the case.  He was excited by the details.  This was something that he had only seen a few times in his career.  He rattled off a number of questions and I answered them to the best of my ability.  I was standing in the hospital lobby by now. I didn't want to risk venturing up to the patient room for fear of losing my mobile connection in the stairwell.

I was about to give the floor and room number when the allergist interrupted me with an unexpected question.

Do you work for the medical group?

He was referring to the large hospital based practice that had recently bought up almost all other physicians in the area.  I knew that he had joined them, but generally don't consider such alignments when making decisions about who to consult on a particular case.  I always try to call the best physician for the job regardless of who they work for.  I paused for a moment before telling him that I was still part of an independent practice.  Although I could sense the hesitation in his voice, I would have never in a lifetime expected what came out of his mouth next.

Oh, um sorry, I only do inpatient consults for physicians who are part of the medical group.

It was such an abrupt surprise, I hung up the phone dumb founded before thinking of the litany of questions that were now pummeling through my head.  Since when does the politics of corporate medicine replace helping those in need?

I'm sounding the Death Knell.

The primacy of patients in our healthcare system has now ended.

Malcolm Gladwell Is Wrong, Tell Them That You Love Them

Malcolm Gladwell thinks we should tell people whats it's really like to be a doctor.  And by God I have invested the last seven years in doing just that.  I have written countless blogs, given lectures, and traveled to Ireland.  I have coined the term Caring 2.0 to describe the bidirectional flow of empathy.  Patients will tell us what it is like to suffer with disease, and we will tell them of our own battles.  Forged somewhere in the molten lava of truth and disclosure, a deeper relationship will arise.  We will heal not only with our hands, but with our hearts.  In the process, the oozing festering gash of our painful existence will somehow be allayed.

Balderdash.

I was wrong.  Years, pages, and a book of poetry later, I have found that my most captive audience is not my patients nor the populace in general, but healthcare professionals.  That's right.  The doctors and nurses are the ones who get the most out of my writing.  It took me nearly a decade to realize that I am preaching to the choir.  It's my fellow PTSD'ers that find release by reading my words.

We are wounded soldiers searching not for a pat on the back nor a bow of recognition as much as knowing glance.  To share with other human beings the impossibly difficult situations we face only has resonance for those stuck in similarly claustrophobic corners.

Do I want to know all the near misses that occur yearly in our aviation system?  Do I want to hear about the accidental deaths by friendly fire in Iraq? NO.  We want to believe that flying is utterly safe, that our military only protects, and that pain and suffering are twentieth century problems long resolved by our excellent medical innovations.

Your average lay person only wants to hear of death when they are forced to.  Face it when mom and dad are taking their last breaths, but otherwise push it back to the farthest reaches of the denying mind.

We physicians need to tell each other,  We need to confide in our brethren.  For those of us stuck in the thick mud of human destruction, the divide is too great for the uninitiated.

But there is something we can do to fight the colossal mess of what Healthcare has become today.

Instead of trying to explain the tangled mess of our daily lives to our patients, we should instead assure them that we are on their side.  We should tell them that we won't stand for the destruction of humanism in medicine by the cold calculus of technology.

We should tell them that we love them.

A Review Of The White Coat Investor

As physicians go, I feel like a relatively savvy businessperson.  Although I don't talk about it on this website, I have owned and run a number of small businesses and been a landlord for years.  So when James Dahle sent me a copy of his book, The White Coat Investor, A Doctor's Guide to Personal Finance and Investing, I was both curious and skeptical.   What was the guy going to teach me?

Before diving in, I took a few moments to glance at his blog.  My few moments turned into hours.  The site is a trove of important and often perplexing subjects that physicians (as well as other small business people) face.  Ever contemplated these issues before:

To buy or rent property?
What defines good disability insurance?
Term or whole life?

These, as well as many other topics, are covered in a concise and digestible manner.  I urge you to take a look.

The book is an easy read.  In the first few chapters, James sets the stage for why we need to learn this important information.  Physicians are facing the Big Squeeze of rising tuition, low reimbursements, and increasing regulatory hassle.  Becoming a millionaire by age forty is quite feasible, but takes a certain amount of planning and know how.  One must be aware of how to convert high income into wealth.

Chapters four and five are indispensable for physicians in training.  Here James dissects how our decisions early on influence our future fortunes.  Such topics as loan forgiveness programs, and whether to buy property during residency are covered.  These are issues that I would have never dreamed about when I was in training, but should have!

For me, an established physician, the heart of the book comes in the next flurry of chapters.  He opens with simple enough advice, Live Like A Resident.  But as the pages march forward, the discussions become more topical and complex.  He handles debt repayment, retirement savings, and the basics of investing with common sense and clarity.  There is a particularly strong and well thought out section about the role of financial advisers.

The last few chapters cover topics that all established physicians struggles with.  Here we learn about asset protection, estate planning, and income tax management.  Any small business person or high income generator needs to understand these topic thoroughly.

In conclusion, for the medical student, struggling resident, or new attending with little financial knowledge, I believe this book is a must read that will save a small fortune both in terms of monetary well being as well as frustration.  For the more advanced investor like myself, these chapters form a stellar check list for us to rate ourselves against.  After reading this book, I clearly understand the strength and weakness of my own financial plan.

I've made a few changes already!

Proof Of Life

It's not that I was stressed out about being alone with the kids.  My wife had gone out of town before. It was the darn mornings.  I'm used to racing out of the house at the crack of dawn, when the rest of my family is still asleep.  My most productive hours of the day are before most people even wake up.  With my wife gone, the mornings with the kids were all mine.

Accordingly, I lounged in bed an extra few minutes before dragging myself into the shower.  Unlike most mornings, there was really no rush.   The kids wouldn't be up for another half hour, at least.  When they did awake, I would busy myself with their needs: dressing, breakfast, and of course, the dreaded hair.

For the next few days, managing my six year old daughter's hair was my sole responsibility.  And this terrified me more than a crashing octogenarian on life support.  Barely able to pull together my own personal appearance on a daily basis, preparing girl hair was definitely going to be a challenge.

It wasn't that I hadn't been prepped.  My wife, daughter, and I had a practice session before her departure.  But we all know that anything can go wrong on game day.

So there my daughter stood on a step stool as I tried valiantly to brush out the curly unruliness of sleep from the tangled tendrils.  Occasionally the brush would stick and she would protest whimperingly until I withdrew pressure.  As I had been taught, I parted the red sea evenly forming a straight line on top.  But as the slope of her head dove down, the part became a mangled twist of tributaries forking and bending towards the nape of the neck.

I grabbed a clump of hair clumsily, trying to entangle the band into a pony tail.  With each second that past, my daughter became more wiggly underneath my hands.  She hummed a nondescript tune and darted back and forth randomly.

My brow furrowed and the sweat formed at the base of my receding hair line.  My ineptness of hand was interrupted by the clarity of thoughts coalescing in my brain.  On any given day, at this time in the morning, I could find myself entrenched in the human condition.  Ensnared in an end of life discussion, examining a pus filled wound, or lamenting on the lack of response to a last ditch treatment.

You can't be in this profession long without realizing that the joys and pains of life are but fleeting flights of fancy.  Happiness is neither a place or a thing, it's a series of disconnected moments.  The more of these we have, the more we recognize, the closer to nirvana we come.

And we often recall the big ones: when our eyes first locked with that of lover, or a child slithered through the birth canal and into this great state of ineptitude that we all share.

But I can't help but think that there is a certain divineness in the minutia.  Standing in the kitchen with   my daughter's hair slipping through my hands as she dances to a silent song that only plays in her six year old brain, I can't help but think there is something important happening here,

I can't help but think that this is one of those moments.

One of those moments that make a life.

Are You A Physician Or A Secretary?

I'm no economist.  In fact I have never taken any business or accounting classes in my life.  But it doesn't take a formal education to get this.  We are speeding down the wrong path.

The call at three in the morning woke me from a deep sleep.  I fumbled and strained to hear the whispered voice of the apologetic nurse.  Apparently Mrs. Thompson had scraped her arm against the wheel chair, and suffered a minor abrasion.  No harm, no foul.  Except that ever since the state had come in  and eviscerated the nursing home protocols, extra precautions were being taken.  Some things just won't be left till the morning anymore.

My early trip to the hospital was no better.  My personal assistant called to say that I had to re do the form to get one of my patients a walker.  Although I had signed it by hand, we had typed in the date.  Apparently the medical equipment company required that the date also be written in ink.  It sounds minor, but I had to find a fax machine, wait for the fax to arrive, write in the date, and fax back.  All, of course, needed to be done immediately.

Luckily my hospitalized patient was getting better.  And since it was neither an admission nor discharge day, I just might escape without wasting too much time on paperwork.  As I was putting on my coat, the head nurse stopped me in my tracks.

"I just need to notify you that your patient claims she is missing fifty dollars, and can you sign this form acknowledging that you have been informed."

What?  Since when did I become a policeman?  Since when did take charge of all criminal activities that take place inside the hospital walls?  

Healthcare is being overrun.  Government induced regulation and documentation are creating mental gridlock.  The dictates of our forms and procedures are tying up those with the physical and intellectual know how to care for patients.

Why can't you get an appointment with your doctor?  Why are diagnoses being missed?  Why is the quality of healthcare in the United States declining rapidly?  Stop querying big data and start looking at the hunched backs and sore shoulders of the people who are inputting that data.

We are turning our physicians and nurses into scribes, field workers, and secretaries.  Those who create the most value, who took the most time and money to train, are being overloaded with menial and level inappropriate tasks.

No small business would be naive enough to operate this way.

Why then, should one of the largest sectors of our economy.

Ribs

The drink you spilt all over me
"Lover's Spit" left on repeat
My mom and dad let me stay home
It drives you crazy getting old

Sometimes I pretend, in the moments before waking, that I am a child once again.  That instead of this old hapless body, I am unencumbered by the chains of longevity.  In these unconscious waves of semi reality I am unaware of the degraded muscle and brittle bone.  I jump up and down on the bed and than race out the door through the endless fields of corn.  My father, the stocky build of a farmer, runs after me.  Before his skin became old and sallow.  Before I watched them lower his body into the ground.  I was middle aged by then.

This dream isn't feeling sweet
We're reeling through the midnight streets
And I've never felt more alone
It feels so scary getting old

They are all dead now: mom, dad, my sister.  After my son died, they brought me to this place.  They thought that I was mute after the stroke.  I guess it had never occurred to all those doctors that I may not have wanted to talk.  And of course, if you don't speak, you must be stupid.  

The staff comes to my room and yells at me in loud, slow tones.  I stare at them determinedly but don't dare make a sound.  Who would believe it now?  I whisper in the midnight darkness to no one in particular, it reminds me that I am still here.

Everyone I know has died.  A hundred years of motion, it appears that my body doesn't know how to follow them.

I want them back (I want them back)
The minds we had (the minds we had)
It's not enough to feel the lack (I want them back, I want them back)
I want it!

The only one who comes to visit anymore is the doctor.  He clucks quietly as he examines my belly underneath the sheets.  I see the wrinkles.  The skin of his jowls hang down like mine.  He is the  only other soul in the building as old as me.  After he visits he asks the nurse to sit me up in front of the window.  I watch the cars slow down and the breaks lights before turning the corner.  

I am alone.

You're the only friend I need (you're the only friend I need)
Sharing beds like little kids (sharing beds like little kids)
We'll laugh until our ribs get tough (We'll laugh until our ribs get tough)
But that will never be enough (but that will never be enough)

That will never be enough
That will never be enough
That will never be enough
That will never be enough

That will never be enough 

*Lyrics courtesy of Lorde, from Ribs

Motion

The first thing I become cognizant of is motion: the beating of the heart, the contraction of the muscles as I place the phone back onto the base or into my pocket, the shallow breaths that willow past the lips.  Only then do I contemplate notifying the family and giving my condolences.

Death has followed me from childhood.  Not as a specter lurking in the darkened corners but more like a willing companion in a yet undisclosed game of strategy.  And as far as professions go, there is a false intimacy in doing what I do.  To experience the aftertaste of mortality on such a regular basis without partaking in the bitter nectar, to place the little white cancer stick to ones lips and yet never inhale.

We are disconnected, I and those I tend to.   It is never so apparent than in those seconds after the last breath is taken.  There is a undeniable stillness in death. Anyone who has been present in the moment immediately can tell the difference.  There is a transition from the living, breathing, and circulating to inanimate object.  No matter how much we slow our bodies, blood still pumps, oxygen exchanges, and diaphragms pull down.

We look to the ephemeral, talk of such things as spirit and soul.  I am at a loss in such conversations.  Because as the warmth returns, I take a deep breath and make the phone call.  I stumble through the words I have mumbled so many times.

I am so sorry for your loss.  It was an honor and a privilege to take care of your loved one.  If there is anything I can do to make this better..

But in reality my oft repeated words carry a certain hollowness.  In an ocean of uncertainty they are merely tiny flecks of wood bobbing up and down in the great vastness.

They are utterances, vocalizations, vibrations that remind both speaker and listener that we are not yet standing upon the abyss.

They are motion.