How the Corporatists Stole Quality

As I was finishing residency, we talked increasingly about “quality metrics.” In primary care, these included diabetic control, hypertension control, depression control etc.

These are all worthwhile goals. We should be trying to control and manage these chronic diseases as improving their treatment will prevent a large number of expensive and debilitating complications down the road.

Now that I am out in the real world, the importance of quality metrics varies wildly from system to system. Additionally, as a locums, I don’t hear much about it. Moreover, I am in the ED more often now and those metrics don’t apply.

Not surprisingly, cash-strapped rural hospitals are often a little behind the zeitgeist. So, their definition of quality is different than what I was used to in residency.

Clinicians Don’t Decide

What I have learned more about is the culture of metrics. Clinicians rarely determine metrics or their system for collection. Administrators is optimize metric collection for themselves, not the people who are actually trying to achieve them.

Administrators manage the system, so it is natural they would try to manage that system to make their jobs easier. What that has translated to is doctors being data entry clerks.

I could maybe even stomach this if it meant administrators actually improved the system. Yet, that seems rare.

I can be a team player.

Instead, what I usually see is administrators trying to game the system to make the metrics look good. Rarely will they roll up their sleeves and get their hands dirty trying to make the system work for the people who depend on it.

Moreover, there is still a pervading fear of liability in administrative circles. So, administrators translate the idea of quality, of improved care, to mean low-liability care.

Low-liability care is not quality care.

Sometimes they overlap, but the goal is completely different. We can expose patient’s to loads of unnecessary tests, procedures, and risks and still have low liability-care. Rise of c-section rates, anyone?

Yet, we all know that is not quality care. The corporatist administrative class doesn’t care. The concepts of black-eyes and feathers in their caps are what motivates the culture of the administrative class , not patient outcomes.

Moreover, systems can charge for many of these interventions. It is a win-win for an administrator – charge more money and decrease liability at the same time. Why do it any other way?

The Institute of Medicine’s famous To Err is Human report pointedly articulated how systemic flaws are often the cause of poor patient care almost 20 years ago. Nonetheless, we cannot hold the stewards of these systems personally responsible for failing to manage systems appropriately.

Layers of obfuscation and bureaucratic interactions prevent us from holding people accountable. Only nursing home administrators even have licenses that can be revoked.

I want to emphasize this point – even though the evidence is clear that systemic processes are at least as responsible for poor patient as clinicians’ actions – only clinicians have a licensing process.

Would administrators care more about actually providing good patient care if they could lose their career through licensure revocation? It might at least lead them to feel more responsibility for the systems they manage.

How did we get to this point?

I think physicians have been trying to keep their heads down, see patients, and get out as soon as possible. The rVU gerbil wheel has tricked many of us into abrogating our duty to try and make things better.

Additionally, as physicians, we treat one patient at a time. Our training to think of problems as individual in nature can sometimes constrain our problem solving.

What if physicians received training in organizational theory and leadership as a standard? Would it be better? I don’t know. But, I know we can’t fix what is wrong with American medicine one patient at a time.

Systemic problems rarely have individual solutions.

“The only thing necessary for the triumph of evil is for good men to do nothing.”― Edmund Burke (disputed attribution)

The Struggle is Real

I shake myself out of the blue light stupor of my computer screen, it is 11 pm on a call shift, I don’t have to be awake. It has been pretty easy – this place sees less than 1 person/24 hours in the ED.

But, I can’t stop my mindless scanning of real estate websites and various gadgets on Amazon. I don’t even like gadgets. We aren’t planning on a buying a house anytime soon. But I can’t seem to stop.

This is a known symptom for me. I rarely buy anything. Real estate browsing is pretty safe – I have never made a impulse home purchase at midnight on Zillow.

Even Amazon rarely tempts me into an impulse purchase. The closest I get is adding something to a wishlist – usually to be forgotten.

The disease attached to this symptom is feeling stuck. I do this when I feel like I am not working towards something, just living in a gerbil wheel holding pattern.

I am really, really bad at assembly line life. So, I start to browse Amazon, Zillow, Airbnb – fantasizing about something else. Mindlessness sets in.

It is not good for me. I almost always feel worse afterwards.

“You are imperfect, you are wired for struggle, but you are worthy of love and belonging.”

― Brene Brown

I am coming to think happiness is overrated. On the other hand, being miserably is obviously no good either. However, I think too many of us confuse elation or rapturous joy – that mountaintop emotion – with happiness.

The thing is, people have never lived on mountaintops, they live in the valleys. A life on mountaintops is unsustainable – ask someone with a Bipolar Disorder just after they have finished a manic phase.

Wind River Range Wyoming, Public Domain.

Moreover, no one has ever started down the road to a significant accomplishment with the phrase, “Things are pretty good right now, I am happy with this.” And per Brene Brown, human beings are wired for struggle.

Survival doesn’t just happen in the wild. Every day is a struggle and humans are no different. I tend to feel most alive and full when I am in a good meaningful struggle.

On the hand, when you actually complete something, like say becoming a doctor, it can be unsatisfying. Then you are back and stuck in between struggles.

Humans need a struggle, a purpose, something to strive towards. We are always looking for more, for improvement. It is a pretty good survival mechanism, constantly looking for advantage.

I think this is an impulse consumerism taps into. It is also why it can be a hard habit to break. Sure, sometimes we are trying to fill a void or a hole.

“If I can just solve this couch problem, I will have figured out life.”

Of course, more stuff never fixed anything. I have never been much of a consumer. I don’t like spending money – I never even get the fleeting joy of something new a lot of people describe. But, the temptation is still there.

So, if I am not actively trying to fill a void with more stuff but still feel the need for something more – where is the problem?

Is the problem I am not content with my current situation? If that is the case, then the solution is working on being content with now or trying to change my situation.

Or, is the problem that my struggle mechanism is just spinning in circles with no focus? If so, then I need to find some struggle to throw myself into.

In Northern Minnesota, where I have spent some time, it is common for families to have lake cabins or houses for family vacations. They are often old and the harsh climate requires frequent repairs.

The classic joke is that the old Norwegians and Swedes would only take vacations if they felt like work. As long as the cabin needed fixing, there was an excuse to head up to the lake.

Maybe I need a cabin….or at least more hobbies.

A Note of Gratitude to Medicine

The end of the year is always a time for reflection.  The darkness leads to more time indoors, more time with our thoughts, and often with our families.  Reflecting on this difficult year is a strange exercise for me.

A Tumultuous Year

My wife and I have passed the one year anniversary of my daughters birth and death.  Moreover, I am now more than 6 months into my new gig as a traveling critical access doctor.  Life has started to settle into a bit of rhythm. 

After all of the grief and upheaval of the last year, simply living a relatively normal life can be rather unsettling.  I seem to even seek out problems or reasons for dissatisfaction.  I have a bit of a restless soul – a blessing and a curse.  

For one, the holidays seem to be a negative trigger for me this year. 

I always struggle from the time the clocks change to the first week or two of January.  The loss of light affects my mood for the worse.  Prior to last year, I had a great ambivalence about the holidays – neither a grinch nor a lover of the season. 

The Shadow of a Loss

That being said, last year’s holiday season was not a good one for our family.  The holidays came very quickly on the heels of our daughter’s passing and I was on call for a good bit of both Thanksgiving and Christmastime.  

With those memories so fresh, this year’s holidays are hardly buoyant.  Sure, the pain is not as fresh and does not burn quite as bad, but its shadow stills falls on the season.  

Living through this holiday season is like walking through the burnt-out shell of an ash-covered family home.  The shock and wailing pain of watching the flames tear everything apart has past.  Nonetheless, an eery sadness lingers over everything. 

To keep myself from falling into a hole of self-pity, I have taken some advice to actively practice some gratitude.  God knows I have plenty reasons not to feel gratitude, but I also have plenty reasons to do so.

Giving Gratitude a Chance

Even last year, my wife and I took time to be actively grateful for the arrival of our daughter, even if her presence with us was far too short.  She taught us a great deal and the heart cannot be overfull of love.  

Finding gratitude about the current state of medicine and my role in it takes a little more effort. I have written a lot about my experience in medicine and life over the last few months (and it hasn’t all been rosy).

Yet, I also remember the ones and things we love are often what can hurt us the most.  My relationship with medicine is much more complicated than it once was.  

I struggle to accept the imperfections of a system charged with healing yet is highly profit driven and largely inhumane. 

This system charged me a steep entrance fee.  The cost comes in actual dollars but also in time and stress and tears.  In the end, I felt expendable.

Yet, I also have to remember the care our daughter received in that same system.  I cannot forget our neonatologist sitting in front of our house with us as we held our daughter without tubes or machines for the first and final time. 

Humanity does still course through the veins of our healthcare system, even if the system neglects it at every opportunity. 

Nonetheless, My Privilege is Great

Doctors are a pretty privileged lot, all things considered.   I don’t mean to minimize my own or other’s distress at the current state of affairs.  On the other hand, I see how my situation may have played out very differently for someone else.

Few other careers exist where you can quit your job, move to another state, and have to turn down work immediately.   That is how it worked out for me. 

I simply showed up and had my choice of work location and practice type within my speciality.  Not only that, but I have been able to improve my worklife balance with an acceptable sacrifice of income.  

Physicians skills are in such need that not only was I able to find a different job, but a completely different way of working.  Hard to complain. 

Medicine giveth, and medicine taketh away.

Work isn’t Everything

Even more importantly, medicine had given me wisdom.  Caring for people who were very ill or had suffered great loss or trauma gave me access to life’s most difficult moments.  Few other professions allow for the gaining of such wisdom without personally suffering those blows.

Learning how to help guide people through their struggles led me to read books and literature I never would have read otherwise.  This knowledge was invaluable when our daughter was born.  I didn’t have a how-to guide, but at least I knew the big ideas.

Most importantly,  I had learned the value of connection.  When our daughter was born, our gut reaction was to circle the wagons, raise the drawbridge.  My patients had taught me this was not the right move. 

Love and loss must be shared, inextricably linked as they are.  We called friends and family and offered for them to come to meet our daughter.  To be present with us in a difficult time. 

Without exception, the responses we received were full of gratitude.

“We are honored to come,” was the common answer.  

In our moments of grief, this might surprise us, but it shouldn’t.   Wouldn’t all of us respond the same way if someone we loved extended us the same offer?

Moreover, the decision has paid great dividends.  To those who met her, the people we love, our daughter is not simply the nameless baby we lost.  She was a person, has a name.  We can talk about the shape of her nose, or her special little movements with so many people. 

Having her in more people’s memories does not just preserve her memory, but means she was even more alive when she was here.  Hell, we even have a social security card for her.

It is the caring for patients that taught me this knowledge before my family needed it.  In the end, I am still thankful for medicine.

“When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that which has been your delight.”

― Kahlil Gibran

Mindfulness on the Fly

The Walk

I can feel the increase in pressure as the shoulder straps dig into my shoulders with every heaving step up onto another piece of talus.  I just crossed the eleven-thousand foot mark.  Five miles and fifteen hundred vertical feet, not all that bad, considering.    

The dry winter has opened up the high country early, so I am heading to a small glacial tarn that is about 500 vertical feet and a half-mile off trail.  I have only put my rod together once in the last 6 months.

Struggling out of an alpine willow thicket, I drop my pack in view of the lake.  More like a pond really – but deep as a lake. 

The Water

This high water is not on the official stocking list for the state’s department of natural resources.  Yet, the trout seem to overwinter well in its deep cold water.  Moreover, it has no passable outflow to lower waters so the trout are safe from whirling disease and other such pests. 

They sit under the ice all winter, waiting for their brief 4 months of feeding.  I have timed it well – iceout was just last week it appears.  One full shoreline is still snowbound. 

I pull out some medjool dates and a water bottle, slowly chewing each date and rinsing it down with cold spring water from the lower slopes.  I stand up and start getting ready. 

A wind comes down the glacial valley from thirteen thousand feet and chills me.  Despite the physical discomfort, it feels good, or at least right.

The Ritual

I pull out my rod, closely inspecting and aligning the four pieces as I assemble it.  Shaking the handle, I watch the energy dissipate down the rod like a fencer preparing for a bout. 

I pull out my reel, attach it to the rod handle, and begin to string the line along the length of the rod.  With each narrowing loop the line passes through, I can feel the troubles left behind.  

The student debt, the house payment for the house that hasn’t sold yet, the crisis of faith in my supposed calling, I feel them each dropping off.  The only stress left by the time I have attached the leader is the loss of my daughter. 

Yet, hers is a welcomed sadness.  I didn’t come to forget her loss, but to be quiet with it – alone. 

Opening my flybox, I pull out a dry-fly – the elk hair caddis.  I know I’ll probably have better success with a olive bed-head wooly bugger – I almost always do.  Nonetheless, part of the ritual is the dry-fly.  

The First Cast

I hop out onto a large rock at the edge of the shallows.  Gently moving my right arm back and forth, I let out line.  After a half-dozen or so passes, I gently place the line down on the water’s surface where a trout might be cruising.

Island Lake, Wind River Range, WY.  Source: USFS

The tuft of elk-hair floats serenely on the water.  I give all my focus to watching the water and the fly.  It gently sways on the water as the wind moves over the lake.  I slowly gather line in my left hand. 

Feeling myself tense, I am fully in the moment with the water, the invisible fish, the mountain, and the sky.  I am nowhere else, neither in time or place.  I am fully present on the lake, on the mountain, watching this stupid fly. 

Now We are Fly Fishing

Nothing happens.  I try several more casts without any luck. I start to think about what fly I should try next: parachute adams, royal wulff, beadhead woolly bugger. 

At that moment, I hear soft “plop” from the lake.  The fly is no longer visible. I raise my right arm quickly, trying to set the hook, the fly emerges quickly from under the water – without a fish.  

Fly fishing is ritual mindfulness.  It seems that as soon as the future starts to steal your consciousness away, the fish and the water remind you of the pressing need of the present. 

The trout, the line, the rod, the fly, the wind all demand such attention that you cannot enjoy fly-fishing without being a 100% present.  When the mind wanders, you inevitably miss a strike, or catch your fly in stream-side brush.

Only 100% of you will suffice when fly – fishing.  No less.

Heed the Lesson

I take the hint.  I stop casting.  Taking the elk-hair caddis in my fingers, I cut the leader and place the fly back into my box.  I take out a woolly bugger and carefully attach it to the leader.  After checking its fastness, I hop back to shore.

I walk to the other side of the lake where the mountainside plunges in the water with rocky abandon.  Balancing on loose rock and snow I manage to dance over to a sturdy ledge which gives me lateral access to a cliffshelf.  Beginning to swing my arm, I let out the line again. 

I hear the bedhead plop softly into the water in front of the cliff as I finish the cast.  Waiting 20 seconds, I let it sink deeper into the water. 

I begin a slow figure of eight retrieval of the streamer.  The line gently wrapping around the fingers of my left my hand.  Suddenly, the line tightens and the tip of the rod bends sharply.  

The Fish

I firmly and quickly raise my right arm, I can feel the hook set well.  The fish cuts to the left, the line singing as it splices the water’s surface.  I can feel the strength of the fish – normally fish this high are small and hungry, barely fighting. 

I slowly give the fish some line, keeping the rod bent in the process.  The fish takes the extra line and jumps.  It sparkles in the alpine sun as it sails 18 inches about the water’s surface.  

I let the fish play for another 30 seconds or so and the resistance slackens.  I begin to retrieve the line again.  The fish protests, but with less vigor.  The distance between him and I narrows.  Soon, he is next to the ledge I am standing on, inches below surface.  A beautiful fish.  

With my left hand keeping the line taut, I extract him from the water with my right.  Placing him on the granite ledge and holding him in place with my left hand which still has the rod, I deftly grab my needle drivers and thread them into his mouth, catching hold of the hook and removing it.  

I gently place him back in the water and watch him swim off into the deep, clear water.  “That was a nice fish,” I say out loud. Only the wind responds.

The Moment

I clamber off the the ledge and over to my pack. Laying my rod against the pack, I sit down.  I take in the mountainside, the lake, the upper coulee in the distance. Snow still hangs there in the shade.

I watch a shadow of a cloud glide across glacier-scoured granite mountainside, a golden eagle rides a thermal.  The cloud reminds me of my daughter and how I would have like to have shared these moments with her.

I welcome the stinging sadness and let myself feel it fully.  It feels needed.  I breath the thin air deeply as a few tears form.  Not a wailing, gnashing of teeth kind of pain, just a simple reminder of a love lost – yet still here.  

I stop short of mourning the high country fishing trips we never had.  Because we never had them, the future has not yet been and never was.  Hell, she might’ve hated fishing, I don’t know.  But it is nice to sit and pretend we would have done this together. 

So, I sit for a while longer, feeling her fully.  100% present in this moment of grief and joy and peace.  For a short time, I am nowhere else. 

Reactions to Suffering in the History of Biomedicine

an introduction to soteriology and biomedicine

Soteriology is the study of systems of salvation. Every significant religion is occupied with the pursuit of salvation or deliverance.  That begs the question, “From what are we pursuing salvation?” Modern America’s soteriological crisis increasingly affects the world of Biomedicine.

Biomedicine is the system of medicine which relies on the application of physiologic and biochemical principles to attempt to heal suffering (in other words – modern Western Medicine).  This term is helpful as a contrast with other medical traditions which rely on spiritual or natural principles to heal suffering.

Over the last several hundred years, Western culture has had several changes in its soteriological orientation.   Prior to the industrial revolution, salvation was solely the realm of the church.   All sufferings: physical, social, psychological, spiritual were in the Church’s domain.

Christ after the flagellation and the christian soul, by Diego Velázquez

The Church provided actions and direction to people in an attempt to ameliorate suffering.  Prayer, supplication before God, and confession were central tenets and ways to address suffering.

Christianity largely places the attainment of the salvation on the other side of death.  As such, the Church had little to offer in terms of preventing, curing, and ameliorating worldly suffering.  Comfort – yes.  Solutions – not so much.

The rise of the enlightenment, the industrial revolution, and advances in all forms of study, including Biomedicine planted the seeds for Modernism to arise in the late 19th century.

the rise of modernism and medicine

Over the course of the 19th century, and into the early 20th, Western societies increasingly placed faith in science, technology, and “progress” to deliver societies from many of the woes of life.

However, Biomedicine was rather late to the party.  Rapid advances in Biomedicine did not really begin until the turn of the 20th century.  The Germ Theory of Disease was still only postulations until the late 19th century.

Thus, by the time medicine began delivering great advances (such as antibiotics), Western society was in the throes of Modernism and the worship of technology, science, and progress.  At the same time, psychology was providing competing ideas for explanations of human behavior beyond sin and virtue.

These allowed for the sidelining or religion in our soteriology.

World War II was a wake up call for many in the West. Wholesale destruction through intensely technological war caused a great many to doubt the cult of technology.  Suddenly, technology was not only a means of deliverance but a means of suffering as well.

Again, medicine seems to operate on a delayed timeline.  The Modernist phase of medicine seems to have continued well into the 1990s. During that time, Western society moved Biomedicine to a central role in its soteriological framework as religion was increasingly sidelined.

The emphasis on science, technology, progress and objectivity also often led to objectification in medicine.  The Tuskegee Experiments are an example, and on more mundane levels House of God is a critique of the worship of progress at all costs.

By the 1990s we had gone from worldly suffering as something to be endured for eternal salvation to a belief in technology’s ability to eliminate worldly suffering to the destruction of Modernity’s golden idol.

[M]edicine is deeply implicated in our contemporary image of what constitutes the suffering from which we and others hope to be delivered and our culture’s vision of the means of redemption. In a civilization deeply committed to biological individualism, one in which the spirit is an ever more residual category, the maintenance of human life and reduction of physical suffering have become paramount.  Health replaces salvation. – Medicine, Rationality, and Experience: An anthropological perspective.  Byron J. Good.

postmodern medicine

In response to Modernism’s technological hubris and blind spots, Postmodernism arose.  Postmodernism is primarily a reaction to Modernism’s inability to deliver on its promises and a critique of its excesses.  Most centrally, it rejects the idea of objective truth.

Moreover, Postmodernism offers no hope of salvation, no road for progress.  Many criticize the cynicism of post-modernism.

Postmodernism’s affect on Biomedicine is multifaceted and interesting.  The challenge to physician autonomy and authority can be seen as one of the first entrances of postmodernism into Biomedicine.

The patient-physician relationship’s hierarchical nature and the many times this led to ethical violations (again: Tuskegee Experiment, or HeLa Cells) made it a prime target for postmodern critique.

The culture-bound nature of  Biomedicine also leaves it open to the critique of objective truth on the part of postmodernism.  Think about your own practices.  How many different ways of practicing medicine have you seen?

Just like any other healing tradition, Biomedicine is subject to its own mores, traditions, and taboos.  Some of what we do is based in science, but much it is not.

Sure, some of the variation can be attributed to local differences in populations and disease, but most of it is purely cultural.

I.E: We do it this way because it is how we have always done it this way.

the postmodern patient

This has led to the rise of the post-modern patient.  As individual physicians are no longer arbiters of reality, patients feel empowered to have opinions on their care.  In the hands of reasonable individuals, I think this improves care.

People’s values and beliefs are important in their care.  I used to tell medical students, the most effective treatment plan is the one the patient will actually follow.

However,  many people have values and beliefs which are destructive to their health and well-being.  Physicians no longer have the cultural authority to offer corrections, as all beliefs are equally valid in the Postmodern office visit.

The main problem with postmodern’s influence in medicine, to my view, is it offers no hope or structure.  Postmodern Biomedicine has no soteriological framework.  It is simply a reaction, not a scaffold.

Additionally, many people are now so distant from their previous soteriological traditions (religion or other philosophies), they are drowning in meaninglessness. As the quote above states, health has replaced salvation for many in our culture.

Here’s the rub:  Everyone’s body will eventually let them down, everyone suffers, everyone dies.

In a world where health is a manifestation of your righteousness, illness threatens not just your body, but your soul.

How can you make sense of your suffering if it itself is evidence of your failure to attain redemption?  You can’t.

What’s the next best option: numbness.

existential crisis

“Today, our view of genuine reality is increasingly clouded by professionals whose technical expertise often introduces a superficial and soulless model of the person that denies moral significance. Perhaps the most devastating example for human values is the process of medicalization through which ordinary unhappiness and normal bereavement have been transformed into clinical depression, existential angst turned into anxiety disorders, and the moral consequences of political violence recast as post-traumatic stress disorder. That is, suffering is redefined as mental illness and treated by professional experts, typically with medication. I believe that this diminishes the person,”
― Arthur Kleinman, What Really Matters: Living a Moral Life amidst Uncertainty and Danger

In a worldview devoid of possible redemption in exchange for struggle, the struggle becomes meaningless.  Our existential crisis in the face of meaninglessness has been medicalized and medicated.

I increasingly view benzodiazepines, stimulants, narcotics for chronic non-cancer pain as a society wide attempt to anesthetize our collective existential crisis.

Our postmodern malaise is just too painful and we have no path to redemption no hope at deliverance. So, increasingly we seek a near constant anesthesia.

“We are healed of a suffering only by experiencing it to the full.”
― Marcel Proust.

is oscillation the answer?

Increasingly, Metamodernism in the wider world of art and culture is emerging as answer to the Postmodern malaise.  Metamodernism’s basic tenet is oscillation.  The world moves back and forth between diametrically opposed poles so quickly as to be effectively in both places at once.

Can we be naive and cynical at the same time?  Metamodernism posits yes.  This is inherently unwestern as an idea.  Also, it is inherently against America’s puritan roots.  The pursuit of purity is central to the birth of the American identity.

American’s don’t know how to do something 75% – we have to shoot for 100%.   Metamodernism challenges us to accept the world as made of dualities and imperfections.

At a very basic level, physics supports the idea in the natural world.  Is light a particle or a wave?  The answer: Both.

Christianity is very comfortable with oscillation as well.  Are God, Jesus, and the Holy Spirit one or three?  Again: Both.

Can we apply the same ideas to medical practice?

Can we accept Biomedicine is both a culture-bound system of healing and a science?  That no 100% objective truth exists, but yet some truths serve us better than others in a given circumstance? That suffering should be ameliorated, but it is also a necessary and important part of the human condition?

In an amusing twist, accepting oscillation as a necessary aspect of the universe means there can be no one answer to our postmodern malaise.  In order to thrive, survive, and heal we must oscillate as well.





Uh Oh, I Want to Fix Things Again…

feeling the burn, again.

Over the last 2 months, I have been feeling the dread slip back into my work.  I spend the day before heading out of town thinking about the all the crap waiting for me.  This used to be normal, but I haven’t felt this way since I left my first job.

I was starting to worry.  I needed to take a look around and figure out what had changed.

problem 1 – working too damn much

I decided to take some time off in January and February – about 6 weeks.  This is  really easy to do as a locums, you just don’t accept any work for that time.  On the other hand, I won’t get paid if I don’t work.  So, I have been working more than usual to bank some money

In September, I was worried about having enough income to make it through those six weeks (I am still trying to aggressively pay down on my student loans). So, I signed up for any and all work that came a long for Nov-Dec.  For instance, I was on call for 264 hours in November.

problem 2 – location monotony

One hospital gets its schedule of need out about 1-2 months before other locations.  In my anxiety about having enough work, I signed up for a lot of work at this location – 192 hours in November.

Every location has its problems and dysfunctions.  This location’s downsides are: it is near an interstate and serves a more transient, mental health burdened population(more drugs, alcohol, suicide attempts, etc.).  It is also near a prison – so that is always fun.

Summary:  an emotionally draining patient population.

Moreover, because of the its demographics, the hospital gets less funding from the local community and yet the ED and hospital are busier than many of the places I work (and doesn’t pay that much more).   For instance, they don’t have auto-injector epinephrine – too expensive.

Despite these downsides, I didn’t used to mind working there that much.  What changed?  Why am I getting frustrated and crispy again?

in the nomadic world – freedom is all

Nomadic societies adopted their ways of life because the resources in one location were too finite and ephemeral to support a permanent population.

In places with limited resources but permanent populations – i.e. the desert, societies drastically alter the landscape to create more reliable sources of water and food – i.e. irrigation works and aqueducts.

The same is true in my work life.  In order to subsist, I must either be a transient nomad or alter an organization to increase its efficiency and ameliorate its affects on my life.

The continued ossification of medical bureaucracy leaves me little hope for the latter.  So, I live light on the land and move frequently.

For instance, when I work at a hospital once a month or so,  I leave, hand off the remaining clinical work, and move on with my life.  That becomes harder when you are back at the same location repeatedly.

Seeing you on the schedule in 2 days, nurses won’t address a concern as soon as possible.  Instead, they hold onto it, letting it fester, until you have returned and drop it in your lap as soon as you walk in the door.

While understandable, it is frustrating.  Especially because the questions are usually the same ones over and over.  Standing orders, protocols, etc can solve a lot of this busy work.  However, I don’t have the power to enact any such thing at the hospitals where I work.  I don’t fix things, I just see patients.

This arrangement works fine as long as the boundaries are respected.  However, human beings don’t like boundaries.  2 year olds and 92 year olds try and test them all the same.  We just don’t like them.  Moreover, we love feeling like we are getting special treatment.

here’s the rub, i like fixing things

I like finding creative solutions to complex problems.  This is actually why I got into family medicine.  When done creatively and intentionally, the longitudinal relationship in family medicine is exceedingly powerful at preventing disease and improving people’s lives.

The human psyche is exceedingly complex and most illnesses in our society are rooted in behavior.  Finding creative solutions to disease processes rooted in behavior is really challenging, interesting, and satisfying work.  Unfortunately, our system does not value this work.

Moreover, making systems and organizations run well is also primarily a psychological task.   You have to understand the values and motivations of groups and individuals, thereby harnessing them to accomplish the tasks at hand.

Again, as the MD in the room, no one wants to let you do this work because in the short term, they can use you to generate more income.  This is doubly true as a locums.

Normally that doesn’t bother me much because I don’t have to deal with inefficiencies and dysfunctions of a given system on a regular basis. Yet, in my anxiety to make sure I had some financial wiggle room to get through the time off, I started playing with fire again.

getting singed

So, I am a little singed right now.  It shouldn’t surprise me given my workload.  Nonetheless, I have had the benefit of learning another lesson about locums work – better not to wear out your welcome.

But here is the beauty – I don’t have to quit, find a new job, or start attending hours of likely useless meetings to try and make things better.  I just change my schedule, move around a bit.

I employ the millennia-old nomadic solution – follow the rain to somewhere else.

Sisyphys (1548–49) by Titian, Prado Museum, Madrid, Spain

The downside is I don’t get to employ my desire to make things better and the system does not benefit from those skills (assuming I have any).  Yet, my personal experience is systems do not want to improve, only perpetuate, themselves.

So, I ask, Why be Sisyphus when greener pastures are just over the horizon?