Is Meaningful Use Killing Us?

It took days to unravel what happened.

The patient first presented to her cardiologist a few weeks prior. We figured that she must have doubled her amlodipine dose that morning, because her blood pressure was uncharacteristically low. He dutifully documented the hypotension and discontinued the 5 mg of amlodipine, not realizing that she had accidentally taken too much.

Seven days later, her systolic pressure reached the 200 mark. She, of course, didn’t know that. She only knew that her head started to hurt and that she was slurring her speech. By the time she arrived at the emergency room, she could barely move her right arm and leg.

Please see the rest of my post at The Medical Bag.

The Final Gift Of The Dying

I assumed many things that morning.  For instance, I thought it was likely that Ronald's fatigue was from lung cancer that had metastasized to the liver.  Or that he decided to stay in his room in the nursing facility because the decision to elect hospice had finally taken it's toll. I was sure that he was both physically and emotionally spent.  I reasoned that I wouldn't want to get out of bed either.

My visit, however, was much more optimistic than anticipated.  Ronald was jovial and inviting.

And he was spent.

The holidays brought an onslaught of family and friends to his little corner of the skilled nursing facility.  Children and grandchildren travelled half the country.  Acquaintances, both intimate and not so, appeared from corners and crevices around the world.  They all came in with smiles on their faces, and flowers in their hands.  They wanted to talk, and drink coffee, and reminisce.  Ronald smiled so many times that his cheeks hurt more than his chest or abdomen.  His voice was hoarse from laughing, and his belly was full of coffee cake and donuts that he truly had no interest in eating.

Who knew that dying could be so tiring?

We both chuckled for a moment, and then became more serious.  I sat down and began to tell him a secret that is many times lost on those in his situation.  The Dying often have a few basic wishes: to be free of pain, to enjoy whatever time is left, and to know that their loved ones will survive and eventually thrive after they are gone.

The process of dealing with physical pain, and trying to improve quality of life, is exactly what hospice providers are adept at.  The emotional suffering of those that remain after a death, unfortunately,  is frequently difficult to manage.

The final gift of the dying is allowing family and friends to be present.  To be patient as they stammer and sputter.  To rejoice when they show up at occasionally inconvenient times.  And to let them play a role no matter how insignificant.

These were things that Ronald could offer.  These were moments that could bring peace to his loved ones long after his own personal suffering ended.

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.