The ABIM Is Trying to Be relevant; Choose Wisely

The American Board of Internal Medicine is irrelevant.  It has always been.  I realized this when I first certified in Internal Medicine in 2002.  The test was largely fact based and filled with information that I would never need to know in practice.  It did not measure my diagnostic acumen, or my physical exam skills, or my ability to listen and empathize with my patients.

After passing the original test, I forgot mostly about it.  I filed my large diploma sized certificate in a drawer in the back of my office.  You see, I didn't display it prominently because I really didn't care if anyone saw it or not.  It meant nothing.  Not a single patient over ten years asked about my certification status.  It was irrelevant.

A decade into practice I recertified.  This time I was forced to do a number of maintenance of certification activities.  They were time consuming and expensive, but I figured it was the cost of doing business.  I didn't learn anything by participating in these activities.  They didn't help me take better care of my patients, and I didn't exit the process a more informed doctor. It was a waste of time and money.  Irrelevant.

Unfortunately, now the ABIM is trying to be relevant.  Not by creating a superior product or innovating in the continuing education space.  Instead it is foisting a new, sub par, labor-some, and most importantly costly product on its it's physician marketplace.  And it is doing it with the force of governmental mandate (ACA will require board certification as a quality indicator) and tacit support of hospital administrators everywhere (hospitals require board certification for hospital privileges).

This mostly annoying, but previously manageable requirement, has become a thorn in the side of American physicians.

The new MOC is just as irrelevant as the old, it's just a heck of a lot more difficult and expensive to complete.

I feel that it would be overly optimistic to expect the government or the hospital executives to release us from this arduous burden.  In fact, many of us suspect the government cheers on as physicians are forced to close doors and join the big academic or corporate sweat shops.  There is no political will to uncouple the ABIM from healthcare reform.

Hence, we physicians are left with two options.  We can either expose The ABIM as not only irrelevant but also crooked as Dr Wes Fisher has so excellently done.  Maybe this grand foolhardy organization will fall on it's own sword.

Or we can gather together and refuse to certify en mass, and see what happens to hospitals as they try to take away privileges from all their Internal Medicine doctors and specialists.

I think the time has come to make a decision.  Which will we choose?  We better choose wisely.

By the way, happy doctor's day!

My First Dead Body

I assumed she asked because besides being a hospice volunteer,  I was a medical student and wouldn't get spooked by a dead body.  She probably didn't realize that it was my first week of classes and I hadn't experienced much yet.

She walked into the room with her head slightly bowed forward.  She was physically and emotionally exhausted.  Because of a scheduling snafu, there was only one nurse for the entire hospice floor.  This was her second patient to die that day.

She bayed me to come forward and help prepare the body.  I stared down at the lifeless figure.  I don't remember all the details, but I will never forget the stillness.   It was the first of many occasions where I would marvel at the appalling lack of motion that separates the living from the dead.

We were silent.  When she wanted me to perform some task or another she would point with her fingers.  I think we put an ID tag on the toes.  Maybe we cleaned the body and removed any remaining catheters.  The family had come and gone so there were no cosmetic issues of concern.

And then she took out the bag.  We gently rolled the body over and placed it cleanly underneath.  We pulled out the openings around the torso. Then we tucked in the limbs and head.  Finally she started at the toes and zipped up the bag from the bottom until she came to the face.

She stopped.

For me this was the shell of a man who I had never known.  But for her, for her, he was a breathing, feeling human being.  One whose hand she had held, whose family she had comforted, and whose excrement she had helped clean from his weakened and frail body.  She went to close the zipper but she couldn't.  I put one hand on her shoulder and reached over with the other removing her fingers.

She knelt down in the corner of the room and sobbed as I closed the bag.

Through years of medical education and practice there are many images burned into the depths of my soul.  But when I think of my first experience with a dead body, I don't see a body at all.

I see a nurse.

A humble, grieving, beautiful symbol of all that our profession can be.

Updates

I'd like to take a moment to update my readers on the progress of the last month since the publication of my book.

I have been selling copies over the web (click here) , and in person, and have been lucky enough to receive some press:

-Medpage today article: 10 Questions: Jordan Grumet

-Digital Opinion Leaders: 10 exemplary 'social media' healthcare professional mentors

-ZocDoc: The Stories Doctors Keep

-Inquisitr: Reddit Photo Showed Us The Human Side Of Doctors People Don't Want To Recognize Anymore.

I will be appearing on a few Google Hangouts (Dates to be announced):

www.iHealth.TV

The Death Chicks

And I will be doing a book reading/storytelling on April 23rd at Bookends and Beginnings

If you haven't bought my book yet, check it out on my Amazon page and buy it!

If you have bought my book and liked it, please consider leaving an Amazon review, blog, or tweet a link to the book.

You can befriend my Facebook-Author Page here.

You can like my Book Page here.

Thank you again for all your help and support!

More blog posts to come.

My First Lesson In Humility

I remember being more confident that most of my peers.  The look of dread on my fellow interns face pre-call, and the fatigue post-call always seemed unnatural to me.  Maybe it was on account of my life-long pursuit of medicine.  I felt nothing but elation at the newly branded "M" and "D" that came after my name on the hospital badge.  I was no longer a volunteer, no longer a student.  I was a doctor.  And part of that persona was walking into the unknown with a certain amount of confidence.  This was exactly where I was meant to be.

A few months into internship, I admitted an obese lady with a skin infection on her thigh.  I started the appropriate antibiotics and waited.  My resident noting the appearance of the skin asked me to order an X-ray.  I placed the order but secretly was befuddled.  Why order an X-ray?  What on earth was that going to show?

I was on call and busied myself with the drudgery of being the low man on the totem pole.  I admitted  5 new patients.  I drew blood.  I did paperwork.  I spent hours in front of the computer screen looking up labs and filling out charts.  I forgot one thing though.

Maybe it was because I didn't understand my resident's clinical reasoning.  Maybe somewhere in the recesses of my mind I had written the order off as something superfluous or unnecessary.  To this day, I can't explain why I failed to follow up on the X-ray of the thigh and retrieve the results.  Some things may remain unexplained.

The next morning my resident and I breathlessly ran to the patient's room at her nurses prompting.  Her blood pressure was dangerously low and her temperature was sky high.  My resident looked at me in a panic and inquired about the X-ray.  After we stabilized the patient, we ran down the stairs to radiology and glanced at the films.  Our worst fears were confirmed upon staring up at the light box: subcutaneous gas.

The patient had necrotizing fasciitis ( a severe form of skin infection) and needed immediate surgery to remove as much of the infected tissue as possible.  She would likely lose her limb and possibly more.

Years later, I can't help but wonder how much better she would have done if I had seen the film the night before, and surgery had been called immediately.  The patient survived either way, but by a hair.

And I learned an important lesson that night in humility.  A lesson I would be taught over and over again as I journeyed through medical education and beyond.

Disease is tougher, more resilient, and far more cunning than the minds of the medical experts who struggle to tame it.

It is only to be rivaled by the human spirit of our brave patients, who battle day in and day out to survive.

Time To Check Out

It was time to check out.

The trip had been a blast.  There was sun, and water, and too much food.  Of course there were moments of displeasure.  The rain came and went.  The skin turned red and hot, and I slathered sunscreen on almost every hour.  But all in all, I had few complaints.

Of course I wanted to stay longer.  Who wouldn't? There was so much to stay for.  If I was having fun now, who is to say that it wouldn't continue?  I had my family, beautiful scenery, all my electronics, and the ocean.

There was that prickly situation, however, of the contract.  I had only signed on for a certain amount of time.  And there was the money issue.  I had run through all I had been allotted.  My funds were low.  There was only so much my wallet could take.  I had searched every corner, shaken out it's contents including the lint.

Maybe I could stay anyway; lock the door to my room and refuse to leave.  They would come knocking, but I wouldn't answer.  I could cling to the bed, my lifeline.  My clothes would turn dirty and tattered.  My abdomen would became frail and gaunt because I surely would run through whatever tidbits were stuffed away in the little cooler in the corner.

Weak and debilitated, I probably wouldn't be able to enjoy my family the way I had before.  They would come to my bedside every day and hold vigil.  Their eyes drawn and their lives on hold, they would wait for me.

My body would start to itch from the irritation of the bed sheets causing endless discomfort.  The joints would stiffen and the spine would curve unnaturally.  And the beloved sun would be hidden behind the closed shades of my room.  The ocean would be a far off dream, a mirage hidden behind jaundiced eyes.

And I would suffer in this place that I once called paradise.  Suffer as my soul rebelled against such unnatural settings.  My mind might remain clear enough to change and give up this battle, but the muscles of my face may become too weak to verbalize my surrender.    

Nope.  That's not for me.

It had been such a wild, amazing trip.

But it was time to check out.

The Intimacy Gap

I used to think that there was a communication gulf between doctors and patients.  Somewhere in the hub-bub of of the harried office visit some secret sauce was missing.  A divide that was so fundamental that both parties often left the room feeling disjointed and uneasy.  Patients wondered if doctors truly heard them.  Physicians wondered if any one was listening to what they were saying.  The tension ebbed and flowed but never disappeared.  This has been the state of health care over the last decade.  This has been the environment in which I have built my clinical career.

I now believe that the term "communication" is imperfect and lacks the specificity that I am looking for.  I think what we truly have is an intimacy gap.  What separates doctors and patients is a disjointed and unnatural version of intimacy that in no way mirrors the important bonds that we form in real life non-medical relationships.

Let me explain.

A patient walks into the exam room and unloads the most intimate, embarrassing, and frightening secrets to their doctor.  Unlike close friends or loved ones, the physician has in no way earned this privilege.  They had not gained this right through hours of conversation, years of support, or acts of selflessness.  There is no shared struggle or trust.  It is given too freely.

The doctor listens patiently and kindheartedly.  But the interaction can only be so rewarding.  There is no mutual disclosure of secrets.  No bidirectional sharing of intimacy.  The physician remains stone faced, objectively detached.  This is what we learned in training.

The practitioner, conversely, is bombarded day in and day out with urgent and emergent situations.  There often is no normal period to engage and form stronger bonds.  They are shuttled from exam room to exam room trying to put out fires without any of the nicety of experiencing their patients during non turbulent times.

When disaster hits, physicians become immersed in someone else's pain and tragedy.  But when they die, or get better, or move away, we are plucked out of their lives and rarely are present for any sense of closure.  By then we have moved on to the next case, the next emergency.

Disjointed, unnatural intimacy.

I don't know how to solve this problem.

For my part, I have decided the only solution is to strive for mutual disclosure.  Maybe we, as physicians, can tell our stories.

We can tell our stories to those we care for,

so that they may also care for us.


My Book: I Am Your Doctor And This Is My Humble Opinion

 

Behind Every Doctor Is A Patient

Behind every doctor is a little boy or girl who once watched helplessly. Maybe it was her father or grandfather who suffered under the weight of a disease that was deemed all but incurable. Perhaps her own skin was battered and bruised by the repeated trauma of an unrelenting tourniquet.  She swore that when (if) she got older she would protect the innocent from such things.  Her vow was the light that guided her through arduous years of study and apprenticeship.  Her promise was etched into the depths of her psyche like those two dangling letters she worked so hard to get placed uncomfortably after her name on her hospital ID.

Behind every doctor is a medical student or resident.  A young man at first, his innocence was the first casualty of a mostly unexpected war.  At some point that boy saw something, felt something, that was far beyond his repertoire.  The shattered remnants were collected and placed back together into a facsimile of what had been before.  But the sum of the parts never quite amounted to the whole.  Those who looked closely enough could see how porous his nature had become.

Behind every doctor is just a person.  Haunted by the weight of her decisions. Baffled by the foibles of our legal system.  And asked to trade in his most sacred skills for a degree in data entry.  She is tired at the end of the day because she was on call the night before.  He is a husband, father, or son and languishes under the weight of such responsibilities as would be expected.

Behind every doctor is a patient.  Who suffers from time to time just as you do.  Who has good and bad days similar to yours.   Who may be a son of a bitch one visit, and a prince the next.  Don't let the artificial barriers of rank and title confuse you.  Don't let the complicated jargon and technological blockade distract you.

There is so much more in common than could ever pull us apart.

The only difference is that we have always had the privilege of hearing your most pressing stories.

Maybe it's time for you to hear ours.

I'll start by telling you mine.

I Am Your Doctor And This Is My Humble Opinion.