The process of becoming an excellent physician is one of mastery. The passion of the child is replaced by the studiousness of the teenager, and the bottomless energy of the young adult. The leap from decision to clinician takes decades. Forged in the steel of experience, trampled by pain and tortuous repetition, ability accrues.
The apprentice guards his knowledge closely. He bows to the alter of the sacred skill that he will do anything to attain. There is nothing above becoming. The mountain has many peaks and valleys. One never quite reaches the summit. There are only gradations of closer.
The height of all these struggles is the clinical visit. When done correctly, the conductor brings order, coaxing each nuance forward at the appropriate time and pushing back. Pushing back.
Mastery of this process, this clinical encounter, means everything. The pride and joy of a lifetime of work is condensed into a moment. This is where knowledge meets art, passion becomes healing. The only thing more sacred than the skill of the trade itself is the motivation that brought each craftsman to this place. The hope to help our fellow human beings is what coats the bottom of the well.
But mastery has it's limits. The conductor becomes less effective if asked to also manage the lighting. Nuance is lost if water balloons are hurled on stage during the most dramatic moments of performance. And so it has become with physicians. The dictates of electronic medical records, meaningful use, and preauthorization are destroying the carefully crafted skill of diagnosis and management. The drivel of healthcare reform has become the fodder of the clinical visit.
Physicians arms have been tied behind their backs. Now we are being blamed that no one is guiding the ship. You can't demand that doctors improve healthcare quality and cost, yet handicap our most basic unit of skill, our mastery. You can't complain that we are doing a poor job, yet pull our laser like focus away from the patient and point it towards a computer. You can't have your cake, and eat it too.
We complain about salary because it is obvious. In the face of greater regulatory demands, increasing overhead, and more intense scrutiny, physician salary has been flat when adjusted for inflation. For must of us though, money is not the issue. It's more about value.
The demonization of a once proud profession will not solve our problems.
It will, however, alienate us from those we are supposed to be serving.
Saturday, May 17, 2014
Saturday, May 10, 2014
Can I Get An Amen
It's time for the American physician to stand up.
We will no longer bend to the tyranny of bureaucracy, the venom of litigation, or the naivete of legislation. For we have spent many a night sweating on the phone as our dear administrators slept comfortably in their beds stuffed with hundred dollar bills. Our experience standing in the line of fire dwarfs that of any attorney questioned by his client's peers. And we have tended to more constituents personally than any verbose and hyperbolic politician.
Yet the doom and gloom of our current healthcare system is being flung belligerently at our feet. The American physician is beaten, battered, and toiling in a cocoon of self hatred. Caught in a tangled web that binds, our detractors count on our sacred healing oath to imprison us in a system that becomes more constrictive by the day. We are too proud to stand down. We are too dedicated to our patients to bow as the chains are pulled tighter.
We have been judged by the outlying ice that melts at our extremes, and denied the strength of our inner core. We are solid. We are dependable.
You will legislate, you will regulate, you will under compensate. And we will nod our heads willingly.
But when you attack our pride, our character, you cross the line.
We have spent every waking moment since childhood planning for this. We have studied more hours than most can conceive, We have worked while others rested and than worked some more.
We have been placed in the most difficult of situations. We have had to question God regularly. We question ourselves.
We stand tall and proud as American Physicians.
We will not let you cast us as villains.
We will no longer bend to the tyranny of bureaucracy, the venom of litigation, or the naivete of legislation. For we have spent many a night sweating on the phone as our dear administrators slept comfortably in their beds stuffed with hundred dollar bills. Our experience standing in the line of fire dwarfs that of any attorney questioned by his client's peers. And we have tended to more constituents personally than any verbose and hyperbolic politician.
Yet the doom and gloom of our current healthcare system is being flung belligerently at our feet. The American physician is beaten, battered, and toiling in a cocoon of self hatred. Caught in a tangled web that binds, our detractors count on our sacred healing oath to imprison us in a system that becomes more constrictive by the day. We are too proud to stand down. We are too dedicated to our patients to bow as the chains are pulled tighter.
We have been judged by the outlying ice that melts at our extremes, and denied the strength of our inner core. We are solid. We are dependable.
You will legislate, you will regulate, you will under compensate. And we will nod our heads willingly.
But when you attack our pride, our character, you cross the line.
We have spent every waking moment since childhood planning for this. We have studied more hours than most can conceive, We have worked while others rested and than worked some more.
We have been placed in the most difficult of situations. We have had to question God regularly. We question ourselves.
We stand tall and proud as American Physicians.
We will not let you cast us as villains.
Saturday, May 3, 2014
A Jordan Grumet Blog Delivered In Person
If you have 20 minutes and want to know what it is like to experience one of my blog posts in person, check out my comments from DotMed2013.
Friday, May 2, 2014
Why I Don't Agree With @aaronecarroll
I have often spoken of the doctor-patient relationship as a covenant. Our patients bear their bodies and souls in exchange for a thoughtful, engaged, respectful partner in navigating health and disease. This dyad, this trusted space, allows for the breaking of cultural norms and full disclosure. Proper healing is an agreement, it is a relationship.
Although often not spoken of, any successful flourishing healthcare system also requires another sort of covenant; one between provider and society. Let me explain.
Being a physician has changed me. For someone who naively went into this profession hoping to help people, the reality is much more nuanced and difficult. I make decisions hourly, daily, that have a profound affects on people's lives. As a mentor once told me, each successful physician has a graveyard full of patients with their name on it. While I am not that cynical, I have no doubt that even with the best of knowledge and skill (and following medical guidelines and standards to the fullest), people have died by my hand. I am not proud of this. The thought keeps me up at night and wakes me early in the morning. It literally turns my insides.
I have to live with this. Day in and day out, my decisions, treatments, or lack thereof may have immediate and devastating consequences. There is no other profession with such a dire moment to moment routine. Policeman and fireman spend just brief seconds of their career making such split second decisions. Judges, lawyers, politicians, even air traffic controllers rarely deal with these imminent vagaries.
This stress, this fear, breaks us. It can turn the unlucky into a cold shell of a person, a far cry from who they used to be. Those who are introspective enough to recognize PTSD can, with the right struggle and support, learn to once again become effective, emotional human beings.
Being a physician takes it's toll. Not just on our psyches, but on our relationships, on our children. In many specialties the ring of the phone is incessant. Government regulations have become so strict that every time a patient scratches themselves, a physician gets a phone call. Birthdays, anniversaries, vacations, and graduations have all been interrupted. And what is one to say to the poor patient or family. Sorry I couldn't answer the phone to help your poor dying husband, I was at a birthday party?
The hours are difficult. The work is arduous. And many more battles are lost than won.
But there is a silver lining, a saving grace. Along with the above outlined struggles comes something, that for many of us, makes it worthwhile. Many of us will gladly exchange the heartache and pain for what we believed was our due when we went into medical school.
Respect
We expected that society at large would understand the sacrifice of being a physician. The hours, the culpability, the stress. That instead of pointing a finger at us, blaming us for the financial downfall of our system, or beckoning us to defend ourselves in court, a hand of solidarity would be extended much as we try to do for our patients.
Compensation
The idea was that a physician would be provided for commensurate with the amount of hours and difficulty of the work. This work, a calling, should garner enough income to keep the lights and heat on.
Meaning
When governmental regulation and intrusion becomes primary, we have lost our way as a society. Physicians derive meaning from taking care of patients, trying to heal, and comforting. The flurry of paperwork, meaningful use drivel, and insurance hurdles leave no time for the best part of our job.
This is the covenant I speak of between physician and society. Physicians will do arguably one of the most difficult jobs in the world in exchange for respect, reasonable compensation, and the freedom to use their skill in meaningful ways.
@aaronecarroll believes that some physicians are crying wolf.
I believe the medicare data dump, meaningful use, and the SGR mess are signs that the covenant has been broken. Maybe physicians are not dropping medicare yet, but they are retiring early. They are choosing specialties outside of primary care. They are emotionally divesting from their lives work and leaving the patient confused and unsupported.
They are turning their pagers and mobile phones off when they leave the clinic, and letting someone else handle the mess.
Although often not spoken of, any successful flourishing healthcare system also requires another sort of covenant; one between provider and society. Let me explain.
Being a physician has changed me. For someone who naively went into this profession hoping to help people, the reality is much more nuanced and difficult. I make decisions hourly, daily, that have a profound affects on people's lives. As a mentor once told me, each successful physician has a graveyard full of patients with their name on it. While I am not that cynical, I have no doubt that even with the best of knowledge and skill (and following medical guidelines and standards to the fullest), people have died by my hand. I am not proud of this. The thought keeps me up at night and wakes me early in the morning. It literally turns my insides.
I have to live with this. Day in and day out, my decisions, treatments, or lack thereof may have immediate and devastating consequences. There is no other profession with such a dire moment to moment routine. Policeman and fireman spend just brief seconds of their career making such split second decisions. Judges, lawyers, politicians, even air traffic controllers rarely deal with these imminent vagaries.
This stress, this fear, breaks us. It can turn the unlucky into a cold shell of a person, a far cry from who they used to be. Those who are introspective enough to recognize PTSD can, with the right struggle and support, learn to once again become effective, emotional human beings.
Being a physician takes it's toll. Not just on our psyches, but on our relationships, on our children. In many specialties the ring of the phone is incessant. Government regulations have become so strict that every time a patient scratches themselves, a physician gets a phone call. Birthdays, anniversaries, vacations, and graduations have all been interrupted. And what is one to say to the poor patient or family. Sorry I couldn't answer the phone to help your poor dying husband, I was at a birthday party?
The hours are difficult. The work is arduous. And many more battles are lost than won.
But there is a silver lining, a saving grace. Along with the above outlined struggles comes something, that for many of us, makes it worthwhile. Many of us will gladly exchange the heartache and pain for what we believed was our due when we went into medical school.
Respect
We expected that society at large would understand the sacrifice of being a physician. The hours, the culpability, the stress. That instead of pointing a finger at us, blaming us for the financial downfall of our system, or beckoning us to defend ourselves in court, a hand of solidarity would be extended much as we try to do for our patients.
Compensation
The idea was that a physician would be provided for commensurate with the amount of hours and difficulty of the work. This work, a calling, should garner enough income to keep the lights and heat on.
Meaning
When governmental regulation and intrusion becomes primary, we have lost our way as a society. Physicians derive meaning from taking care of patients, trying to heal, and comforting. The flurry of paperwork, meaningful use drivel, and insurance hurdles leave no time for the best part of our job.
This is the covenant I speak of between physician and society. Physicians will do arguably one of the most difficult jobs in the world in exchange for respect, reasonable compensation, and the freedom to use their skill in meaningful ways.
@aaronecarroll believes that some physicians are crying wolf.
I believe the medicare data dump, meaningful use, and the SGR mess are signs that the covenant has been broken. Maybe physicians are not dropping medicare yet, but they are retiring early. They are choosing specialties outside of primary care. They are emotionally divesting from their lives work and leaving the patient confused and unsupported.
They are turning their pagers and mobile phones off when they leave the clinic, and letting someone else handle the mess.
Sunday, April 27, 2014
Are Physicians Becoming Distracted Drivers?
He was rather tall. Or at least he appeared so with his long erect back jutting from the bicycle seat. The cringe worthiness of his helmetless head was assuaged by the gigantic headphones covering his ears. I figured they would provide minimal protection during a crash, but at least he would be listening to groovy tunes.
He weaved in an out of traffic on a busy two lane road. He peddled effortlessly, bouncing to the music that undoubtedly pumped through his brain. His arms were bent, thrust forward towards his head. Did I mention that his hands were no where near the handle bars? That's right, he was riding no handed. He gyrated his torso to control the direction of forward movement.
As he passed by, I was able to divine what he clasped in both hands, and held up towards his face. It was a book!
I was fascinated. He was driving through busy traffic, minus a helmet, listening to music on headphones, without using his arms to steer, reading a book. And I couldn't but help be impressed with this supreme act of concentration. Or should I say distractedness?
If only we all could be this efficient. If we could all multitask to such an extant, what great things we could accomplish? But then again, maybe he was just an idiot. Was he really gleaning all he should from that book in his hands? Was the music moving his soul, or just background noise? Shouldn't he have taken the most minimal of safety precautions and worn a helmet?
The problem becomes that the dilution of concentration during the performance of complex activities is nothing short of dangerous. This is comparatively obvious when talking about bike riding or driving. Sadly, we don't follow the same philosophy with doctoring.
We are told not to drive and text.
We obviously shouldn't ride our bike and read.
Yet no on thinks twice about evaluating sick patients, trying to meet meaningful use, following checklists, abiding by HIPAA, and filling out forms all at the same time.
To me, it sounds like a prescription for disaster.
He weaved in an out of traffic on a busy two lane road. He peddled effortlessly, bouncing to the music that undoubtedly pumped through his brain. His arms were bent, thrust forward towards his head. Did I mention that his hands were no where near the handle bars? That's right, he was riding no handed. He gyrated his torso to control the direction of forward movement.
As he passed by, I was able to divine what he clasped in both hands, and held up towards his face. It was a book!
I was fascinated. He was driving through busy traffic, minus a helmet, listening to music on headphones, without using his arms to steer, reading a book. And I couldn't but help be impressed with this supreme act of concentration. Or should I say distractedness?
If only we all could be this efficient. If we could all multitask to such an extant, what great things we could accomplish? But then again, maybe he was just an idiot. Was he really gleaning all he should from that book in his hands? Was the music moving his soul, or just background noise? Shouldn't he have taken the most minimal of safety precautions and worn a helmet?
The problem becomes that the dilution of concentration during the performance of complex activities is nothing short of dangerous. This is comparatively obvious when talking about bike riding or driving. Sadly, we don't follow the same philosophy with doctoring.
We are told not to drive and text.
We obviously shouldn't ride our bike and read.
Yet no on thinks twice about evaluating sick patients, trying to meet meaningful use, following checklists, abiding by HIPAA, and filling out forms all at the same time.
To me, it sounds like a prescription for disaster.
Monday, April 21, 2014
Let's Be Real Clear About This
Are doctors being overpaid and causing the catastrophic rise in American Healthcare costs?
Let's look at internists:
Well, yes but...
Maybe it is that we American doctors are seeing our patients too often.
Or could this be the problem?
Let's look at internists:
Well, yes but...
Maybe it is that we American doctors are seeing our patients too often.
Or could this be the problem?
Sunday, April 20, 2014
It Takes Something Away From You
When someone asks me about what it is like to be a doctor, a funny thing happens. My eyes start to water and the words catch.
It's rather comical how emotional I can be. I have been all my life. I sometimes feel the sadness flow through me. I am a sieve. Whether it be a touching book or a sappy TV commercial. I cry. Silently. Often missed by others in the room, the tear ducts in my eyes become overactive. And it eventually stops.
I used to be embarrassed. I used to cover my eyes and wipe the tears dry before anyone could see. I don't anymore. As so often in life, I find it much more empowering to own my "weaknesses", embrace it. This is who I am. I'm comfortable with that. In fact, I enjoy it.
We can fight the inevitable pain of life, or we can bask in it. When we allow the skin to become penetrable, emotion soaks right through us, and then out. We become free once again.
I am no stranger to the sufferings in life. My profession, my calling, requires that I squat in the most uncomfortable climes. I have watched hundreds die. I have walked in moments after the last breath has faded, and I have felt the spirit leave the room. I tell people often that the end is near.
And I have done so all these years without shedding a single tear.
It is only when someone asks me about how it feels to be a doctor, that the emotion returns. Here, away from the examining room and aseptic hospital halls, it is once again safe. The heat rises into my chest and the throat becomes dry. And I remember that I am neither dead on the inside nor cold, just in pain.
How ironic to describe a majestic calling from childhood in chocked and unsavory terms. The words struggle to leave my lips in such anemic tones.
It takes something away from you.
It's rather comical how emotional I can be. I have been all my life. I sometimes feel the sadness flow through me. I am a sieve. Whether it be a touching book or a sappy TV commercial. I cry. Silently. Often missed by others in the room, the tear ducts in my eyes become overactive. And it eventually stops.
I used to be embarrassed. I used to cover my eyes and wipe the tears dry before anyone could see. I don't anymore. As so often in life, I find it much more empowering to own my "weaknesses", embrace it. This is who I am. I'm comfortable with that. In fact, I enjoy it.
We can fight the inevitable pain of life, or we can bask in it. When we allow the skin to become penetrable, emotion soaks right through us, and then out. We become free once again.
I am no stranger to the sufferings in life. My profession, my calling, requires that I squat in the most uncomfortable climes. I have watched hundreds die. I have walked in moments after the last breath has faded, and I have felt the spirit leave the room. I tell people often that the end is near.
And I have done so all these years without shedding a single tear.
It is only when someone asks me about how it feels to be a doctor, that the emotion returns. Here, away from the examining room and aseptic hospital halls, it is once again safe. The heat rises into my chest and the throat becomes dry. And I remember that I am neither dead on the inside nor cold, just in pain.
How ironic to describe a majestic calling from childhood in chocked and unsavory terms. The words struggle to leave my lips in such anemic tones.
It takes something away from you.
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