Begin Again

It was a rather unlikely place to begin my clinical career.

Shortly after starting medical school, I signed up to volunteer in the hospice unit of my academic medical center.   The first few visits I relegated myself to fairly banal activities.  I shredded old medical records, or I might do a load of laundry for a family member who had been waiting tentatively by their loved one's side and was unable to carry out such basic human necessities.  Over time I became more familiar and would engage families, sit with the dying, and comfort the staff.  I once helped a nurse prepare a newly deceased body, and as we zipped the bag closed she crouched into the corner and started to cry.

The act of caring for people in a medical setting was new to me.  Everything was fresh and pure.  I leaped at the chance to graduate from the hospice unit and tackle my first home patient.  Unfortunately the day before my planned trip, he fell and was brought to the unit.  I visited him briefly before he died.  I even made a trip to the grocery store, and bought a bottle of white wine for his last meal.

A few weeks later, another home patient requested a volunteer.  I walked through the brisk winter day down the city sidewalks, through the congestion, and stopped short of his building.

Ralph was an octagenerian dying of prostate cancer.  His wife had passed years before, and he had no children or close family.   His daily needs fell to a handful of caretakers who took shifts feeding and bathing him, arranging his personal affairs, and keeping him company.  I came on Thursday afternoons.  Usually we would talk for an hour before he became tired.  Then as he settled in for a nap, I would run across the street and buy groceries to stock his pantry.

Sometimes we walked down the hallway towards the elevator.  He was a poet, and we talked above the rattle of his walker and tentative footsteps. My class schedule was brisk and I had begun my clinical responsibilities.  I often imagined that medical education was somehow diminishing my humanity.  The thrash of knowledge and depersonalization of doctoring was smoothing out my rough edges, and making me bland and unpalatable.  But Ralph would trample me with his walker, replacing my rough edges by and by.

I woke up one morning to find that I could no longer hear his footsteps or that creaky old walker.

Ralph died.

I still think of him from time to time, and marvel at how inspiring it felt to be engaged in the humble profession of taking care of each other.

Decades into my career as a physician, after all the hurt and pain I have been a part of, it devastates me that I no longer know how to get back there.

Again.

December 1996

Footsteps

Help often comes from those we least expect:
Sometimes your footsteps separate my dreams from reality as the echo of your walker disrupts the silence of an empty hallway. 
I dream the great teachers of the world have taken me as their student. With sand paper they smooth the rough edges but all the while I worry that in becoming soft and supple I will lose my character, my humanity. They give their knowledge freely but fight for it back with a vengeance. Your laughter distracts as you trample me with your walker, replacing my rough edges, and making me forfeit my strength by and by.
Recently, our walks are becoming shorter. You no longer have energy to make it past the elevator and after you want to lie down. As we pass our time together we watch our lives float by. Neither of us drowning but both frustrated by our lack of ability to control the direction in which the current leads. You, trapped in a body that can no longer house your vitality and I sleep walking through a world of lost humanity.
I once dreamt that you were reaching out your hand to me. I was surprised to find that instead of needing help you just wanted to shake hands. But then, I was falling into a pit and you were above me, my life line. But the expression on your face was undeniably saying good-bye. I woke up terrified to find that for the first time in months I can no longer hear your footsteps

I know now that you are free……and so am I.

Sometimes Medical Care Requires More Than Just A Minute (Clinic)

The truth is, I know it's easy to go to the Minute Clinic.  I know the enticement of not needing an appointment, of being able to shop while you wait, of having the prescription ready to pick up by the end of your appointment.  Who doesn't like convenience and a friendly smile to add?  Who doesn't like the customer service offered at CVS, Target, or your local pharmacy?  I certainly do.  And I know that the doctor's office can be a pain.  I also loathe the annoying phone tree that leads to a tired nurse or secretary, and possibly the hours of waiting to have the physician call you back and tell you to rest and drink fluids anyway.

Realize, though, that these clinics do not have your best interests at hand.  Of course they can manage the typical medical problems that often don't require much intervention in the first place: respiratory infections and minor rashes and such.  They can even treat your strep throat or urinary tract infection.  Until, of course, something goes wrong.  At midnight when your temperature soars and you are unable to swallow because of tonsillar swelling, there will be no one at Target to prescribe you steroids.  Or when your simple bladder infection turns into pyelonephritis, there will be no expertise available to guide your way.

You then will be stuck calling me, the beleaguered primary care physician.  I, however, am a vanishing breed.  Because I saw the writing on the wall years ago and became a hospitalist, or concierge doctor, or departed from clinical medicine.  And those few of us who are left, certainly won't want to clean up the mess of a pharmacy clinic at some ungodly hour when we would rather be sleeping.  You didn't come to me in the first place, why should I now be responsible when taking care of you has suddenly become inconvenient?

Yep, now you're getting it.  These clinics pick off the easy, high margin care and then punt when push comes to shove.  They have less interest in your well being, and more in your wallet.  Low acuity, high volume primary care can be very lucrative.  Don't expect them to be there, however, when you really need them.

And don't expect me either.

Because I'll be long gone.  Forced to abandon my life's work due medicine's lack of convenience.

Looks like someone will be going to the emergency room.

Good Luck!

In My Humble Opinion; The Most Popular Posts of 2014

These were my most viewed posts of 2014.  Enjoy!

1.Let's Be Real Clear About This...Are doctors being overpaid and causing the catastrophic rise in American Healthcare costs?
2.Doctors Behaving Badly...A dozen set of eyes stared upwards.  The nurses ate their pizza and glanced back and forth between me and the dry erase board that I had recently filled with incomprehensible scrawl.
3.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.
4.Creative Destruction Or Internal Combustion...Everyone seems to have a solution for the primary care crisis.  Businessman and venture capitalist Vinod Khosla thinks technology and big data will replace the imperfect physician.
5.We Will Always Have This...As I have said before, when done correctly,  doctoring is an act of love. 

Thanks again for reading and have a great New Year!

Are We Witnessing The Death of the Modern-Day Physician?

Pamela Wible recently wrote a provocative article on KevinMD regarding physician suicide. In the seminal piece, she conducts “psychological autopsies” on 3 physicians in training who had taken their lives. She searches for answers and suggests solutions for what has become a problem of epidemic proportions. Whereas her focus on the individual is laudable and instructive, I would like to apply her technique to the profession as a whole. While some physicians are committing suicide or becoming addicted to drugs, others are leaving in less-devastating but still consequential manners: early retirement and nonclinical career paths. To many, it feels like a most-celebrated calling is laboring through its last breaths. I stand here today, scalpel in hand, ready to conduct an autopsy of an honorable profession. Are we witnessing the death of the modern-day physician?

See the rest of my post at The Medical Bag.

Is Less Actually More? Should Your Physician Be A Plumber Or A Violinist?

It seems everywhere you look in health care today, some consultant is telling you that "less" is actually "more".  Less care leads to more quality.  Less expense brings better outcomes.  Nurse practitioners with less training are more cost effective.  Less work hours for residents builds a safer hospital environment.

Never in our entire history have we gotten so much for so little.

A recent article on KevinMD by Arshya Vahabzadeh asks whether shortening medical school is a good idea.  A fairly nuanced piece, a balanced viewpoint is given.  I was particularly interested in the conversation surrounding time-based verse competency-based assessment.  In many ways, I think it is helpful to view the changes overtaking medicine through this lens.  

In the old way of thinking, medicine was an art.  Like learning to play the violin, mastery was a distant mountain with many peaks and valleys.  The climber learned technical skills in the beginning: how to hold the bough, how to read music from the page.  These technical skills, however, were the foundation of knowledge, but not mastery unto itself.

Mastery came when technical skills were married with unfathomable degrees of practice, luck, and passion.  No one in their right mind would tell the musical genius to put down the violin for fear of over practicing.  No one would tell them that less practice is actually more.  And so it is with writing, and singing, and even mathematics.  Technical abilities can only take one so far down the road.  There is something intangible that is only gleaned from exhaustive repetition.  

The new view of medicine is that providers are technicians.  More like plumbers.  Now, I have no problem with plumbers, but once you learn how to change a toilet or unclog a pipe, there are only so many variations.  If a plumber can demonstrate their competency in such fields, there is little need to endure more training.  Hence the training to be a plumber, to date, has been less arduous than that of your typical doctor.  

The educational model for physicians today is becoming more skills based.  We now have teams, checklists, and electronic warnings that allow physicians in training to reach competency quickly.  They become facile at entering data and awaiting a clinical guideline to pop up on their computer screen.  Care plans are less individual and creative, and more standardized.  

If this paradigm becomes reality, who really needs a fourth year of medical school?  Or possibly a third?

But, I bet the average patient will not be so happy as these changes take hold. 

At one's most vulnerable moment expecting a great concerto, a virtuoso, how sad to receive a toilet plunging instead.

Is Maintenance Of Certification a Tipping Point? #DisagreeMOC

Physicians are docile.  We are programmed to put the greater good above our own.  We train mercilessly, work tirelessly, and bend faithfully at the alter of those we have vowed to heal.  This is our birthright.  This is the covenant we signed in our own blood when we took our healing oath.  Decry us as they will, no one becomes a physician to make money.  No one devotes decades of education and hardship to take advantage of the system.  There are just too many easier ways to defraud.   Easier ways to earn a buck.

Accordingly, physicians have been far too accommodating.  Rather than rock the boat, we have accepted the spew and encroachment that has come from almost every direction.  Lawyers will sue.  Politicians will mandate and legislate.  Technologists will code and program.

And by and large, we have accepted each bitter pill as it has sucked away the very marrow of enjoyment and professionalism of our field.  We have spent our own precious hours learning how to document better, feeding a torte system that shows no signs of being consumed by it's own wanton wastefulness.  We have slaved over relentless forms and check marks,  each new piece of paper the love child conceived in an orgy of governmental vigor.  And we have hunkered down in front of computer systems stoked by nonsensical technology ignoring the very patients they were created to serve.

The result has been a great emigration away from clinical medicine.  Early retirement. Suicide.  Physicians are fleeing to safer ground.  Better to leave, say the humble and meek, then to fight on the bloody battle field.  The death of a once revered profession is a fate that is all but sealed.  Of course, there is a glut of youths waiting to become medical students.  But the medicine they practice will be barren of the art we so often admire today, full of clinical pathways, and largely driven by less trained assistants and secretaries.

The government has mandated it to be so.  The lawyers, politicians, and journalists concur.  Health care administrators salivate at that juicy stake that has just been stolen off the plate of the so called "providers" and dropped into their lap.

The future had all but been written.  The pathway marked and measured.  The funeral arrangements made.

Except.

Except a tiny overreaching mistake by a greedy group of "once" doctors trying to lap up a small taste of the gravy train.  The American Board of Internal Medicine (ABIM) in an effort to boost revenues announced it's new Maintenance of Certification (MOC) requirements.  These largely unproven, waste of time and money efforts, did something that all the legislation and finger pointing on capitol hill had largely avoided.

It awoke the heart of the lion in the poor bleating body of the lamb.

Dr. Wes Fisher and a number of his cardiologist associates exploded the internet with opinion pieces and exposes regarding the ABIM, conflicts of interests, and the lack of data supporting such testing.  These lone voices have broken the silence of the long barren field of physician advocacy.  The visceral response amongst the populace has grown steadily over the last few months.

I believe we have come to a tipping point.

Maintenance of Certification has become the spark that has finally ignited the beleaguered physician. Faced with a nonsensical health care system mired in administrative minutia, we have found a rallying cry that symbolizes all that trampling we have endured over the last few decades.  The hope rings out from city to city, that if we can just conquer MOC, than maybe meaningful use will be next. Maybe torte reform is on the horizon.  Maybe, just maybe, we can form our own seats at the table instead of be served up for the main course.

We have a number of road blocks standing in our way.  Any practicing physician, not being paid by the ABIM, can tell you that MOC is both a waste of time and money.  However, it is often a requirement of credentialling at our hospitals.  Furthermore, it is only a matter of time before it becomes one of the quality measurements used by the government to determine payment.  These facts must be uncoupled in order to move forward.

I think we must speak clearly with a united voice.

The ABIM board of trustees should be fired, all conflicts of interest must be disclosed.
The MOC should be abolished or radically changed.
The AMA and the ACP should pressure the ABIM for these changes or we should withhold our membership fees.

***

Will this be the death knell of our proud profession or the shock that brings us back to life?  Only time will tell.

I disagree with the MOC.

#DisagreeMOC

To Be Noticed Immediately and Judged Subconsciously

I think I will carry two things with me from this experience.

My body dropped.  Almost instantaneously.  One minute I was jogging next to my wife, the next my mouth and nose were hitting the pavement.  I must have slipped, my foot must have caught. There was no time to anticipate the pain, not even a millisecond to reach out my arms to cushion the blow.  Moments later, I felt the sting upon my upper lip and the taste of blood.  I rolled back and forth on the ground trying to shake off the searing heat arising from my face.

My wife dropped to the ground to comfort me.  Pedestrians stopped inquisitively and pulled out their mobile phones ready to call an ambulance.  I stood up shakily and composed myself enough to ward off the attention.  And we hobbled home, my wife and I.  The blustery wind permeating my light jacket and sending a chill through my aching bones.

At home, I surveyed the damage as my children peered around the bathroom door cautiously.  My front tooth was chipped.  My face was bruised, and the skin beneath my nostril was irritated and angry.  Looking in the mirror, it appeared as if my nose was bleeding, although when I wiped the area there was scant debris on the tissues.  My hands were swollen and sore.

My Friday dinner plans were ruined.  We ordered a pizza, sat on the couch, and watched a movie.  I gingerly maneuvered the crust around my mouth avoiding the front teeth that were tender and numb.  I fell asleep immediately, and woke up early next morning ready to go to work.

Almost every part of my body ached.  My swollen hands screamed as I turned on the sink faucet.  My chest collapsed as I picked up my work bag.  And my lips were still puffy and bruised with the ever present appearance of nasal bleeding.

I hobbled into the car and sped towards the hospital.  Every left turn required a twisting of the wrist that sent lightning up my arm.  As I pulled into a parking spot at the medical center,  a spasm of fear over took me.  Once glance in the mirror confirmed my worst fears.

I looked funny.  All day long I would have to explain what was going on with my face. All day I would see the inquisitive looks before the words formed on people's mouths.  I was abnormal.  I was a monster.

Forty eight hours later, my tooth has been fixed and the bruising has abated.  I still have pain when I complete almost any movement, but it's getting better.

But for a moment, I was the outcast.  Distorted and bruised, I had a small taste of what it feels like to  be disfigured.  To be noticed immediately and judged subconsciously.

And to be in pain.  Not the minor aches that we all feel from time to time.  True pain.  The kind that makes you aware of every movement.  Every step.

In a matter of days, I'll be completely back to normal.

Many of my patients, however, continue to struggle with maladies that are far less kind.