Mental Healthcare, Still Excising the Stone of Madness?

My phone rings.  I stop walking.  The sudden change in velocity causes the gravel under my feet to let out a slow grinding noise.

I often walk the gravel roads on the edge of town when things are slow, even at night.  Maybe especially at night.  Getting away from the few lights allows the full grandeur of the night sky of envelop me.

It is an expanse I rarely get to appreciate in the city where the smog and light pollution only let a few key stars shine through.

Of course, I am always within 20 minutes of the ED, but at my walking speed, that could be over a mile away.  I answer the phone.

“Hello?”

“Hey Doc, the police are bringing in a guy who has been acting strange and his mother called a safety check on him. So, they are bringing him in for evaluation.”

“I’ll be there shortly.”  I turn and head back to the hospital at a slightly faster pace than before.

The Rural Mental Health Crisis Team

I walk through the doors into the ED.  The standard mental health crisis is now assembled: Two small town police officers, an ED nurse, and myself.  God help this poor soul, because we probably won’t.  At least, not in any way which changes the trajectory of his illness.

“Hi,” Char, my nurse cohort for tonight begins. “So, this is Tim, his mom called the cops because he has been acting strange the last few days.  He is talking all the time, wouldn’t let his mom into his room in the house.  He has had a lot of problems with meth, so, y’know…”

I acknowledge Char’s statement, but also mentally try to put it on a back shelf.

One of the double edged swords of small town doctoring is everyone knowing everyone.  On the one hand, it is quite a bit easier to get a detailed and relevant social history on people.  On the other, people often have their story made up in their mind about who a person is and what is going on.

Could Tim be on meth? Sure.  Does the fact that he’s done meth before mean he is one meth now?  Not necessarily.  I have developed a technique of trying to mentally disprove the suggested theory while also proceeding as if it an equally likely possibility.  It seems to help me find balance in diagnosis.

If You Get Hurt on this Rotation, You Fail.

We did our emergency psych rotation in medical school in the ED of the county hospital, a level 4 trauma center in the middle of downtown.  It was the quintessential urban ED.  On orientation day, safety was the first and last thing addressed.

The attending psychiatrist, a tall, thin man who projected both bookishness and a tempered, pulled bowstring kind of hardness, listed some maxims:

  1. Do your first cursory exam from the door
  2. Never let a patient get between you and the door
  3. Try to project calmness
  4. If you feel unsafe, leave

He finished his talk with this warning: “If you get injured on this rotation, you will fail this rotation.”

Honestly, this was the scariest threat he could have made to a room full of medical students.

Whenever I find myself back in this situation, I stop at the door and do my initial exam.  I look Tim over.  He sitting in the bed, his hands flailing over his head in somewhat rhythmic circles.  If he’d had glow sticks, he would have fit right in at a rave.

“Tim, what’s going on?”

“Just keeping everything together.” He spat out in between his rave routine.

“Are you feeling okay?”

“Oh yeah, I feel great. I just got to keep everything moving.”

“Have you been doing any drugs?”

“Nope.”

“Do you know where you are?”

“Yes, the hospital.”

“Do you think anyone is out to get you?  Do feel in danger?”

“No, but people have been watching me, talking about me.”

“Who?”

“Everyone”

I review the chart.  His heart rate is quite elevated and his blood pressure his very high.  It could be meth, but he also seems to have some paranoia and something else going on.

Of course, true psychosis and meth intoxication are not mutually exclusive diagnoses.

“Give him 4mg of lorazepam IM, if he calms down, start an IV and give him and a liter of normal saline, he’s probably dehydrated and we’ll need some urine.”

Collateral History

I leave and call his mother.  She tells me he smokes marijuana still (of course, I think to myself, marijuana is just a vitamin these days). But, she continues, he hasn’t been acting like he used to when he was on meth.  He has been saying that he has been talking to his deceased father and repeatedly saying everything would be okay because they would be seeing him soon.  He has not been sleeping, eating, or drinking she goes on.

She runs through a disconnected description of the past few days.  She is clearly very shaken.

I return to the ED about a half hour after Char gave Tim his sedative.  He is out cold.  Rousable enough to avoid intubation, but way more sedate than someone psychotic on methamphetamine would be after that much lorazepam.  His vital signs have normalized.

His story is starting to sound more and more like true psychosis, possibly a manic episode.

“Okay, Char, I don’t think this is meth, we should get mental health here.”

“They won’t come til we have a U Tox which shows no meth.”

“Of course, well let’s get that urine then.”

We Count the Hours…..

What is understood between us is how long this is going to take.  The closest emergent mental health evaluator is 90 minutes away.  So, even if we immediately had a magical urine sample at that very moment, we would be 2 hours from someone actually evaluating him (which has to happen before we even discuss placement).

2 hours later, we finally have a urine sample.  We call the mental health evaluator.  She agrees to come.  I go out for another walk.

After Julie, the mental health person has evaluated him, we talk.

“He is psychotic and needs placement?  Right?”  I prod her.

“Oh yeah.  He definitely needs placement.  I have already placed him on a mental health hold. I am going to go start making calls looking for placement.”

“I love you already, Julie.”  She smiles back.

This is music to my ears.  I hate placing people on holds.  It is a huge legal move to restrict their rights and comes with a lot of paperwork.  I love it when someone else does it.  And placing them on a hold pales in comparison to the work of finding a mental health facility to take him, which she is already starting.

Seriously, I love Julie right now.

I stand up and turn to Katie, the nurse who has replaced Char.  This has already gone on so long shift change has already come and went for the nurses.  I am here for 48 hours, so no such luck for me.

“Call me when you have paperwork for me to sign, I am going to go to sleep.  He can have more ativan if he gets agitated again, I wrote for it already.”  I think about ordering him an antipsychotic, but since he is compliant enough on the ativan, I would rather the psychiatrist get to see him in his full psychotic glory rather than already partially treated.

I trudge off to the sleep room.

A New Day Dawns

I wake up to the phone ringing again.

“Hello,” my voice comes out a froggy moan.

“Hey Doc.”  It is Char again, shift change has already happened again.  He has now been here for 18 hours. “Need you to come out and sign Tim’s transfer paperwork, we have placement and transport is on their way.”

“Okay, I’ll be right there.”

I scribble the legal necessities on the paper work and finish my half typed note from the night before.  Honestly, I am pretty pleased at how relatively seamless this was.  It took a long time.  I feel like it went well.

Cynicism Creeps Back In

However, my cheerfulness quickly fades as I am honest with myself about the situation.  Sure, we did what we were “supposed” to do.  Theoretically, the ramshackle network of mental health on the High Plains worked.

If I am honest with myself, all it succeeded at was passing the buck.

I know from experience how this will play out in the end.  He’ll get stabilized on medications in an inpatient setting, then he will be sent back to the High Plains to the care of his elderly mother, where the closest psychiatrist is 2 hours away.  Even then, the psychiatrist is only available 2 days a week.

No one will have the power or will to make sure he stays on his medications.  One day, he’ll stop them, because self-medicating with marijuana feels better than antipsychotics, and eventually the cycle will repeat.

Who knows if he or anyone else will get hurt next time.

Dividing the Care of the Person

This is how we make ourselves feel better so our souls don’t rip in half.  We break down the tasks involved in caring for human beings into such small parts so we can all feel like we’ve “done a good job,”  All the while, for the person, nothing really changes.

This is our “system” of mental health in this country.  A revolving door of failure.

Sadly, I shouldn’t even complain.  I was thrilled to find out such services even existed. In large parts of rural America, the same patient would have been placed in the local jail.  In many towns, the jail is the only secure location in town for these people until placement can be found.  At least Tim avoided that fate.

I played my part in this farce brilliantly.  We efficiently and effectively “placed” Tim.  Who could find fault with my actions?

Of course, it is not my fault we have such a failure of a mental health system and my participation does not mean I own all of its sins.   Nonetheless, it is just one more of the millions of tiny cuts physicians endure to our souls while working in our healthcare system.

The history of mental healthcare is filled with terrible and inhumane practices. Will we look back on today the same way?  We might not be lobotomizing people anymore or cutting into their heads looking for the “stone of madness,”  but we should not delude ourselves.

Repeatedly sending ill people into a world their brains cannot process to self-medicate with drugs and endure repetitive trauma through physical and sexual abuse at the hands of each other is not a more humane choice.

At least the old quacks cutting the stone were actually trying to cure something.

Featured Image: Cutting the Stone, Hieronymus Bosch, 1494 or later.

What is Being Present Worth to You?

…Memories of presence…the intensity of interacting with another human being that animates being there for, and with, that person.

Arthur Kleinman, The Lancet, Vol 389 June 24, 2017 Pg 2466.

“Doc”

“What do you have?” I ask the paramedic with the clipboard standing in front of me. The ED is rather busy. I am trying to arrange transfer of a man with an intra-abdominal abscess and one with neutropenic fevers. The prospect of more work does not excite.

Hank, an older paramedic who really enjoys the “medicine” part of his job, launches into his presentation.

“Rex Mayfair is a mid-forties man with a history of metastatic prostate cancer, Stage IV presents with urinary retention since this morning. This happens occasional for him and he comes in and we place a foley and have him follow up later. I already bladder scanned him, 570ml, and our scanner has been underestimating lately. Can I place the foley? He’s hurting.”

“Any fevers, weakness, blood in his urine?”

“A little bit of blood earlier, none now. Otherwise no changes from his baseline. He is not currently undergoing treatment for cancer, but is not on hospice. Can I place the foley?”

“Sure, go ahead. I’ll be in a bit.” I am relieved he has such a simple complaint. Something straightforward. Shouldn’t slow us down too much.

I return to organizing antibiotics and transfers for my other two patients.

Cancer Just Sucks

Eventually, after I tie up some loose strings, I make my way to Rex’s room. By the time I get into his room, Hank has already placed the foley, 1000ml out, and Rex is feeling better. My participation is really only procedural – a physician needs to physically see every ED patient.

I have a confession to make, I hate cancer. I hate how all consuming it is. As someone who initially trained in family medicine, cancer makes me feel as though I have already failed. The time for prevention was long ago. Now we sit at the mercy of the tumors.

Bad cancer makes me feel helpless. Doctor’s hate feeling helpless. Rex had bad cancer, and he was young.

Walking into the room, seeing Rex’s young, gaunt face makes me want wrap this up as quickly as possible. I only need to make sure there is no reason to suspect this is something other than swelling related to the cancer and I can rush him on his way. This should be quick…

To be Present or…not

“Hi, Rex, I am Dr. HighPlains, are you feeling any better after the foley?”

“Oh yeah,” Rex says in a defeated sigh. “It is better now.”

He just looks so damn tired and weak. I inhale deeply, but shallow enough so Rex didn’t notice. I sit down in a chair, recline slightly, and prepare to be here for a while.

After a few perfunctory ED questions, I asked Rex how things were going otherwise.

“It sucks, y’know, it just sucks.” He admitted.

“I can only imaging how much it sucks.” My patterned doctor-speech.

“I hurt all the time, cancer is in my bones. My hips and back, they ache all the time and then trigger muscle spasms.”

Without probing, he tells me how his urologist diagnosed him after 8 months of treatment for prostatitis. He describes how he was on hospice for a bit, but didn’t want to have a catheter permanently yet, so now he is not on hospice, but not pursuing curative treatment.

I simply nod in silence. His eyes are sunken and tired, but whenever he looks up, mine are there to greet his and hold his gaze as long as he desires it. He pauses frequently, but never seems done.

He continues, again without probing. He decided not have chemo because he has a form of muscular dystrophy. His oncologists told him the chemo would render him bed-bound from weakness.

“I would’ve had no quality of life…it just sucks, y’know.” He trails off into silence.

“Yes, it does.”

You Don’t Have to Ask a Dying Man

What do you say to make someone who is dying feel better?

It is a trick question, of course. Not because there is nothing to make them feel better, rather the thing involves no speaking. The answer, it turns out, is simple: you listen.

You listen. Even when it makes your own heart break, you listen. You listen through the descriptions of pain which makes you wilt. You don’t have to ask a dying man anything.

If you listen, he will tell you everything he wants you to know.

Rex isn’t done. He tells me about the facebook groups he’s found, which have been helpful to fight the isolation of living in the middle of nowhere with end-stage cancer.

He describes how much he used to enjoy driving the bus which took local elderly to events in the city and hearing their stories.

He misses that.

He tells me again about the pain. He tells me how his doctor prescribed him oxycodone for the pain, but he doesn’t like taking it. It makes his sleepy.

He has two little girls. When he took the oxycodone he just slept all day. His voice trails off, but I hear the implication.

He would rather be awake in pain with his daughters than sleep away whatever time he had left with them.

“It just sucks y’know, I’m only my forties, not an old man. Shouldn’t have to have a tube up there….it just sucks….” He bows his head, the brim of his baseball cap hiding those eyes, deep-set in his sallow, bony cheeks.

At that moment, it was a good thing I was listening, I couldn’t have said anything if I’d tried. I was speechless. My mind whorled in appreciation for the beauty of his simple statement.

“I have two little girls, I just slept all the time.”

This man, who has all the right in the world to numb himself from the pain of his situation had decided being present with his family was worth the pain.

Maybe when someone tells you the name of the thing which will probably kill you, time becomes palpably more dear. I don’t know.

What would I suffer through to give my daughter better memories of her father? What would I suffer through to have those memories and make more for as long as I could?

Few of us face a choice so stark, but in some way or another, we all face Rex’s choice. We can choose to be present in our lives and in pain, or choose to chase numbness.

I sat in a room with courage that day. I sat in a room with a man who chose to live his life rather than run from death.

Occasionally, if we let ourselves, we can awed by those we see through our practices But, we have to let ourselves sit in acceptance and receive the gift. I could have easily kept moving and had Rex on his way.

Instead, I sat down, and I am richer for it.

Featured Image: The Artist’s Father in His Sick Bed, Lovis Corinth, 1888.

A Shift as Death’s Attendant

“When was the last dose of epinephrine?” I ask the Tara, the recorder.

Her blood is everywhere. My gloved fingers are tacky with it.  I see it dripping off the edge of the bed, smeared across the floor, oozing from the open fracture of her right leg.

Her foot, connected to her leg only by skin and tendon, was still in a shoe. This struck me as an obscenity.

I watch blood pulse back forth in the tube draining her chest with the same rhythm as the chest compressions.

Tara’s reply makes its way through the commotion, “3 minutes ago.”

I turn to the team.  “Get ready to give another dose of epinephrine. Pete, take over chest compressions at the rhythm check.”

“Still in asystole.”

“Resume compressions, give the epinephrine.”  My voice has so little emotion. It seems to simply echo the recordings of the ACLS trainings I just completed the week before. Good timing, I think to myself.

On the Banks of the Styx

This is the second time in 48 hours I have stood at the foot of the bed, directing our modern dance with death. 

36 hours ago, it was all for show. We surmised he was dead well before his family found him. But EMS started CPR in the field, so we continued it. We invited the family in, to see us try and bring him back to life. We showed them all we could do.

We added artificial adrenaline to his veins. Then, when the lab-made adrenaline did nothing, we gave him our own – in the form of chest compressions, bagged breaths, and sweat-beaded brows. We danced with him, this newly dead man. We danced for his family.

We danced so they would know the drama and pain of the moment when we had done all we could.

He gave his body to those he left behind. He allowed us his body as salve to the grief of those who would miss him.

Dance of Death, replica of 15th century fresco; National Gallery of Slovenia

He sacrificed his body to lighten the burden of guilt of those he left. He didn’t make that choice, we and his family made it for him. I don’t know if he would have wanted it, but I found the gesture noble.

Now, 36 hours later, I am back in the same position. But this woman, she came in alive. Now, she was dead.

Only by standing at the threshold do you see how thin the veil really is.

Despite the intubation, the fluid, the pressors, the chest tube, her heart had stopped.

A code can actually have a lot of down time, especially once chest compressions have been going on for 20+ minutes.  I take a moment to let my mind slide out of the algorithm.

I look at the woman on the bed.  She is elderly.  I can hear the crunching of her multiple rib fractures with each compression.  Dying in a car crash after you have lived so long.  Such a violent death, so unexpected at that age.

“Doc, I have the family on the phone, can you talk to them?”

“Yes.” I grab the phone.  “This is Dr. HighPlains.  How are you related to Gladys?”

“I am her son, what is going on?”

“What have they told you so far?”

“Only that she’s been in a bad car accident.”

“Yes, she has. When she came in she was having difficulty breathing and had severe fractures in her legsand ribs. We had to put a tube into her lung to drain blood that was keeping her from breathing and put her on a ventilator. “

He sighed audibly in the phone.

“We started giving her blood as she was bleeding internally. Despite all of this, her heart has stopped and we are now doing CPR to try and restart her heart….I am so sorry.”

“We are currently doing everything we can do. However, in my experience, given her injuries, it is unlikely we’ll be able to get her heart restarted.”

Silence.

“Do you know what would your mother have wanted us to so in this situation?”

He regained his voice. “Well, I am her Power of Attorney. How long have you been doing CPR?”

“About 25 minutes.”

With a tired, tremble in his voice, “I need to get my head around this, Would you keep trying for 10 minutes, and then, if nothing changes, you can stop.”

So, the music continued. And again, we danced. And Gladys too, sacrificed her body for those who will grieve her. We all tried not to focus on the grating of the ends of her ribs past each other.

It is such violent dance, these days.

Time of Death, 18:00

12 minutes later, I made a phone call.

“Sir, this is Dr. HighPlains again. Unfortunately, we were unable to get your mother’s heart restarted…”

“Thank you for everything you’ve done…”

We share a few more words, and I hang up the phone.

The Strange Calm

The routine of operationalized death begins. I sit back and watch. I slowly peel off my trauma gown. The ball is over, no point keeping up the dress code.

I watch the nurses. They cover the body first. It is a body now, no longer a person, at least medico-legally. Staff has already notified the coroner. The transfer of care is in process. I no longer have a patient.

The nurses start gathering the detritus up and throwing it away. I help feebly. We draw the curtain in the trauma bay. It is customary to the give the dead their privacy.

But, whose sensitivities are we really protecting?

Breath, Light Awareness

I sit down at the computer. Documentation is impatient. I pause before I start typing. I sit and feel. I notice my breath, and my pulse.

Luxuries, I suppose.

I can feel the heaviness of death. I do not feel guilt, I do not feel shame. I did everything I could. Could we have used dopamine instead of levophed, sure. Could we have tried externally pacing when her heart rate started to drop, sure.

Nonetheless, I do not second guess. Death sits next to me in heavy silence. I do not shy away, nor do I linger in fascination. I allow my body and breath to relax in acceptance. All our paths end here.

Click…Click….Click

“Patient arrived by EMS transport in extremis….”

What is the Art of Medicine?

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” – William Osler

I have spent literally years of my life pouring over the “science of medicine.” I dedicated innumerable hours to memorizing biochemical pathways, pharmaceutical mechanisms, and equations for physiologic processes.

American Medicine assumes the science of medicine is the most important. We view it as an exceedingly important part of the training process. Yet, any physician will recognize the science only gets you so far.

Sadly, organized medicine dedicated much less of my formal training to learning the other part of medicine, the art. In medical school, the recommendation for learning the art of medicine was simply to watch someone who, in your opinion, was particularly good at it and emulate them.

Thanks, that’s helpful….

No one ever even defined what the art, in fact, was. Even now, when I search for a definition, a significant amount of variability in the definition floats around the internet.

Some say the art of medicine is the space in between the evidence and practice, the judgement we use when science cannot give us a clear answer. The art simply smoothes out the edges of the science in the real world.

On the other hand, others posit the art of medicine is the relationship, empathy, and emotional aspects of doctoring. It is the space we keep for humanity in the practice of medicine. The art of medicine is the properly placed hand on the knee, the right words said in comfort, the knowledge of the patient as a person beyond their disease.

I think both these definitions and all others that I have read sell the art short. They do not give the art its due place in the pantheon of our skills. Only recently have we began trying to teach medical students any skills which approximate the art of medicine.

What is Art, Anyway?

“Science and art,… they seek the truth and the meaning of life, they seek God, [and] the soul….” – Anton Chekhov

I don’t think we can truly answer the question of the what is the art of medicine until we actually understand the goal of art and the artist. Chekhov, who was both an artist and a physician, articulates the overlap of art and science well – seeking truth.

Science and art both quest for truth. Science seeks to understand the rules of the natural world so as to understand it, predict its outcomes, and hopefully influence them for our purposes.

Art, on the hand, seeks to create an entire world, the experiencing of which leads us closer to human truths. These are truths a scientific experiment cannot elucidate, because they exists only in human souls.

The human experience is often a reaction to the chaos of the world around us. Much of what plays havoc with our lives is beyond our control. Through art, humans create worlds where we mute the chaos, understand it, and give it meaning.

So, we will find the art of medicine in its truest form not in clinical judgement or in human actions, but in those moments where we the physician partner with patients to create new worlds in the pursuit of healing.

The Healing Art of Narrative

The essential task of the healing patient-physician relationship is the creation of a world where the destruction and chaos of illness is rendered understandable, and if possible, meaningful.

Which artform allows physicians and patients to create a world where healing is possible where only hours before there was only suffering? It is the art of narrative, of a story’s telling and untelling.

Make no mistake, the history is the first part of a patient encounter because it is the most important. The history, the patient’s narrative of the illness is what creates the backstory in which any healing must occur.

In the very moment when a patient tells you their story, they are creating the world in which their suffering exists and their healing must occur. Narrative must be heard to exist.

The act of hearing, of bearing witness, is just as integral the creation of the world as the telling. Notice the word bear/born in this context. Bearing witness midwives the world of the sufferer into existence.

The Use of Narrative

So, the patient has shared their story, you have born witness. The world has been created. As a clinician, you must accept the history. You can interpret it, but only for yourself.

If, as the clinician, you deny the truth of the history, you deny the existence of the patient and her story altogether. A person whose world has been denied cannot heal. We cannot “correct” the history. We must accept it and move forward in the pursuit of healing.

“A well-thought-out story doesn’t need to resemble real life. Life itself tries with all its might to resemble a well-crafted story.” 
― Isaac Babel

It is in these moments I believe a true practitioner of the physician’s art can shine. Through discussion, empathy, reframing, and a healing relationship the patient and the physician can together, begin to build a story about the illness, its affect on the patient and their world which opens the possibility for healing.

A New and Sudden Frailty

I am reminded of a man I saw in follow up for a hospital discharge after a heart attack, or MI. He was in his mid-sixties, generally healthy. No hypertension, no smoking, minimal lipid issues. The MI came out of nowhere.

The ED physician, cardiologist, and hospitalist had all done exemplary science. The physicians diagnosed quickly, treated appropriately, and discharged him with minimal loss of function. Nonetheless, he was in a stupor, rudderless.

Despite being grateful for all that his hospital team had done for him, he still felt less a person than he was before. He was struggling with the sudden transition from being a healthy, active, strong man to a man with a chronic disease. He went from no medicines to at least four daily pills.

As the physician, you must acknowledge the loss. What this man lost was his health innocence. He lost his ability to take his health for granted. He lost his ability to feel strong, vital.

And Now We Create

So, here is the exposed fulcrum of healing. You can imagine how this could go. He retreats into himself and begins to hide from activity that he worries could bring on another heart attack. He gains weight, starts to feel depressed, his relationship suffers.

At this point, he loses more than a small amount of heart muscle, he starts to lose life itself.

This would be possibly as devastating as the MI itself. For what is life without vitality? The deepest art of medicine lies in this moment, when together, we help this man build a new narrative for his life.

Hopefully, the narrative is one rooted in his past and which does not ignore the transition that has occurred but allows him to re-engage with the world as the richer person he now is.

Jan Steen – The Doctor’s Visit

This process is alchemical, because it depends on everything that is individual about the person. It is a tenuous moment.

It is a verbal and emotional dance that weaves the story of healing out of the tattered fibers of loss.

We as physicians in this moment must engage directly with this loss, its grief, and our patients’ human frailty and help them build a road out of the fear. Some people can do this on their own, but many cannot.

That, I argue, is the art of medicine. That is what an algorithm cannot predict and metrics cannot tell us. Not clinical judgement, or acronyms of empathy, but a truly engaged art of healing.

Who Built This Leaky Ship?

People who don’t use it, that’s who.

On a recent shift out in the great wide open, I saw a patient who I see frequently in this location. He is a chronically ill man in his 70s with chronic kidney disease and multiple sclerosis (MS).

His MS took his ability to walk, so he is wheelchair bound. On top of this, he has bilateral indwelling nephrostomy tubes which frequently are the source of infection.

He should be receiving dialysis, but he refuses to move to a city where it is an option. Dying in his hometown is preferable to moving to the City to receive dialysis.

He lives in the nursing home (NH), which is attached to the hospital and emergency department. Whenever he becomes febrile, the nurses in the nursing home send him to the ED where we culture his urine, start him on antibiotics and either send him back to the nursing home with follow up or admit him to the hospital.

When he is through with his course of antibiotics, he often goes to the City as an outpatient and has his nephrostomy tubes exchanged. This buys him about 2-4 weeks before his next infection sets in.

It appears we are purposely trying to breed some sort of resistant bacteria in his urine by this rodeo. All of his acute care is generally done by the ED physicians (locums), whereas his chronic care is managed by his regular physician.

Despite the chronic, repetitive nature of his ailments, both teams of physicians treat each infection as isolated, acute events. This is sadly the standard in American Healthcare.

Welcome to the Norm

All over America, we treat patients for their acute issues and then send them on their way. Rarely do we address the underlying issues at play, which have led to the causes of the acute issues.

Even in hospitals, most acute issues we treat are exacerbations of chronic disease: COPD exacerbations, CHF, MI, GI bleeds from chronic anticoagulation or NSAID use, infections related Diabetes or the above chronic diseases. It is the rare patient in the hospital who has a new onset, isolated, acute problem.

Even in medical school, our cognitive training focuses on isolated cases of acute illness because it is difficult to teach concepts of diagnosis and treatment in the milieu of the chronically ill. So, our brains become accustomed to looking for the single, acute issue.

Search satisfaction is a strong bias.

Moreover, the way the systems reimburses us emphasizes episodic, not longitudinal care. This method of care delivery works very well for acute, isolated incidents of illness in otherwise healthy people. Sadly, these people are exceedingly rare.

I posed this question to an ED nurse friend recently and he guessed otherwise healthy, financially secure people made up about 2% of the patient’s he sees. That is in an acute care setting.

So, who came up with this crazy system?

“We build a broken system and then ask people to try to fit into the system instead of tailoring a system around people’s actual needs.” – David Brooks

The roots of our system date back to isolated private health insurance companies. Those companies inherently catered to otherwise healthy individuals with money (those people make insurance companies money, after-all).

However, I think the root of the problem is deeper. Generally healthy and wealthy people designed our system. Chronically-ill 80-year olds are not in government and insurance boardrooms.

Therefore, episodic acute care makes up the bulk of the decision makers’ personal healthcare experience. They don’t know the professional patient, or if they do, they assume he/she is an abnormality.

Indeed, in the broader population, the hospital-dependent, chronically ill are a minority. However, at least in my practice, I spend more than half of my time with people who would fit this description.

So, we have a system designed for the people who aren’t using it, or use it only rarely.

Meanwhile, the people who depend on the system for their continued survival have to make do with a system which treats their care inappropriately. It rewards treating their problems, rather than managing their total package of care.

Is there hope?

In the short term, I don’t see much cause for hope. Too many people are making an absurd amount of money off the inappropriate care of the chronically-ill. And if I am honest, I have to include myself in that group. Effort vs. money, acute care is easier because the system incentivizes it.

I tried to do global care as a primary care doc, but the model of the outpatient setting is one doctor and one-two nurses/medical assistants. You cannot provide the necessary basket of services and harangue all the help you need with such an anemic team.

The system is trying to move more care to the outpatient setting because it is cheaper. However, we have ignored and underfunded the primary care clinic for decades.

As a care delivery model, it is severely atrophied. So, the system is moving sicker and sicker people to the outpatient setting without first strengthening it. As such, people will burn out and turn over and the attempt will fail.

Until the system incentivizes keeping people healthy over treating the sick, any changes will only be a veneer.

The Hard Work of Doing Nothing

I looked at my schedule and read Ed Schwartz’s name. I was surprised. Ed doctored reluctantly and never had much need to. He is 55ish, thin, athletic, and generally quite healthy.

Ed always refused to tell my MA his reason for visit. “Not any of her business” was the usual reason. So, I always went into the room not knowing what I was walking into.

I met him first for a wildland firefighter physical, his post-retirement gig. Not your average primary-care patient. He was proud that he could hike two miles with a 50-lb pack faster than most 20-somethings taking the wildland firefighter physical test.

In that visit, I had learned he had moved to the area from Northern Michigan. He had spent 20 years as a police officer, pensioned out, and then started and sold his own business thereafter. Now, he was partially retired and found odd jobs wherever he could to keep active.

Entering the room, he looked his normal stoic self. He was sitting the chair, upright and rigid. Thin and hard-looking with steel-gray eyes that could be intimidating when he needed them to be.

We began with pleasantries, he had finished his summer season (it was November now) and most of the fall chores on his property and things had started to get slow around the house.

“I’ve already piled all the brush up and now we can’t burn the piles til it snows. I don’t have much to do and have been gettin’ a bit squirrelly”

The reason for the visit finally comes out

With him being around the house more, he and his wife had started fighting. He owned that most of the conflict originated with him.

“If something doesn’t change, she might not put up with me much longer. Y’know, I don’t do great with the shorter days and I know the last two winters here have been harder because I don’t have something to do all-day, everyday.”

“Too much time can be a burden on a lot of people,” I offered.

He fidgeted a little, the heal of his cowboy boot grinding into the carpet.

“I have always been an active guy. In the force, I took all the overtime I could get. I worked all the time – nights, weekends – all of it.. Then, when I had my own business, I worked all the time, made good money, and eventually sold the whole business. I was damn good at it.”

“I can tell, Ed.” I agreed.

“Now, I see,” I think to myself. Addiction to overwork – the coping mechanism of the “successful.”

Ed softened a little. “But y’know, Doc, when I don’t have work, I get cranky, irritable, I snap at my wife. I get worked up easily.”

“Have you ever talked to anyone about this before?” I asked.

“Yeah, once Y’know. A few years back, over the winter, I was on a pill, Prozac, I think. It seemed to take the edge off. I was wondering if that might be a good idea again.”

Primary Care – Psychiatry without the time.

We went through the screening for major depression and generalized anxiety, he was mildly positive for both. More on the anxious side thought.

“I think that some medication would be a reasonable idea. Have you ever done counseling?”

“No, I don’t like the idea of talking with people about these things. It doesn’t seem like my thing.”

He then proceeded to talk with me about “these things” for quite a while. He talked about being first on the scene of a car accident with a dead teenager. The boy was the son of an acquaintance. He had never been able to tell the father he was the first on scene.

“Last month, we were visiting, and he brought up losing his son, I just stood there, feeling so mall.” His held his hand out, index and thumb fingers less than inch apart. “Just like a nothing.”

“That sounds very difficult. Sounds like you might have a lot of experiences from your previous lives you haven’t dealt with. It might be helpful to talk with someone about those things.” I offered.

He looked down. “Yeah, maybe, but I think I’d rather just try the medicine for now.”

We discussed the pros and cons of medicine, counseling, or both. In the end, pills were the plan.

I was not shocked.

Being still, wallowing in our avoided pains and anxieties is enticing to no one. Yet, it is necessary for growth.

Bison – wisely doing nothing. Photo Credit: NPS

Why Can’t We Do Nothing?

Doing nothing is hard work. Some of the ancient philosophers comment on the “laziness” of overwork. To them, breathless activity without direction, simply as a reaction to stimuli, could be seen as complete lack of discipline.

Never mistake motion for action. -Ernest Hemingway

What I have seen in my medical practice is that overwork is often used to keep the mind from reflection. Reflection is the time we take to examine our lives and actions. During reflection, we plot out future action and measure our relationship with the world.

Without reflection, we cannot separate our own action from motion.

Apparently, what lies beneath and inside many of us is very scary, or at least uncomfortable. I see so many people working or at least busying themselves to death, rather than confront their inner selves.

Reflection is difficult territory and requires great courage and discipline. This is why the Buddhists must have a “meditation practice” and why religious mystics have always hid in high, remote monasteries – because the pull of busyness is very strong.

Being still might be the hardest thing

It is likely difficult to have time to be still in all professions. Nonetheless, I have found time for reflection is highly undervalued in the world of medicine.

The thing is, taking the time to do nothing directly benefits only ourselves – at least initially. No one else will carve out time for us to reflect, to measure ourselves and our actions.

It takes extreme discipline to hold the line against Hospital-Pharmaceutical Complex and make room for doing nothing. It is arguably the hardest thing to do in a career of medicine.

I was reminded of this fact reading M’s recent post over at Reflections of a Millennial Doctor. The world will take everything and ask for seconds.

“But, Dr. HP, you could be making more widgets. You could be helping more patients. Isn’t that important to you, Doctor?”

Interestingly, the FIRE blogs are generally full of people whom life has forced, in someway or another, to be still for a moment. However, few seem to have chosen to take that time of their own accord – myself included.

There is always more we could be doing. The question we must answer first is what should we doing.

We cannot answer this question without first taking time to do nothing.

When Winning Prevents Success

One of the great lessons I took from my experience in my first job was to spend more time with a potential team before signing on a contract.  Things are often not as they seem.  My partners sold me a specific image of the practice.

They were, they said, a tight group of doctors who were passionate about providing rural healthcare in all settings: clinic, nursing home, emergency department, and hospital.  This was the perfect description of what I wanted to do, I thought.

I left my first medical staff meeting thinking, “What the hell is going on here?”

The vitriol, anger, and greed I heard in that meeting shocked me.   I had never heard people talk more aggressively about money.  Anytime someone floated a proposed change to staffing, coverage, or practice the meeting devolved into a squabble over potential effects on earnings.

I had thought that my partners were passionate about providing healthcare to this rural community.  Instead, they were passionate about making as much as possible while providing healthcare to this community.  Now, I am sure they would disagree with my assessment – greed seems perennially justifiable.

I have thought a lot about how we said the same words and yet meant completely different things.  I have boiled it down to the difference between these two words: winning and success. 

Why Winning and Success are not synonyms

While winning and succeeding seem similar aims, their underlying requirements vary in one significant way: comparison.  We must have a yardstick to assess a win and success.  The difference is which yardstick we use.

When framing accomplishment in terms of winning and losing, the yardstick becomes the performance of another competitor.  When we talk about success, the yardstick can be any number of measurements.  Success can stand on its own, a win necessitates another’s loss.  A near limitless number of participants can share in success, it does not demand a vanquished competitor.

Success is a far more inclusive goal than winning. 

what does this have to do with medicine?

Physicians’ ranks are subject to intense selection bias.  The process of getting into medical school is rigorous and very specific.  As such, people who get into medical school have tendency to be highly organized, driven, and ambitious.

Being ambitious does not require being competitive.  However, in American culture, it is almost always synonymous.  We arrange our culture into a series of competitions.  As such, medical students have a strong tendency towards competitiveness, or winning.

What happens when everyone in a room has organized their lives around the pursuit of winning?  They need to win.  For many, their entire personal identity is wrapped up in the idea of “being a winner.”

In a world organized around competition, if you aren’t a winner, you are, by definition, a loser. Therefore, someone else has to lose to keep a winner’s personal identity intact.

The winner’s ego demands the sacrifice of others to maintain its self-perception.

If excellent leadership is present, these tendencies can be harnessed to provide a cohesive team culture focused on conquering some external competitor.  Unfortunately, that takes truly excellent leadership, which is rare by definition.

culture changes slowly

Something I did not appreciate until I arrived in the “real” world of medical practice, was how change in medical culture lags our culture at large.  Due to the hierarchical nature of training programs, the long delay between joining the profession and being in a position to affect change, new voices take a long time to be heard in medicine.

Historically, medical training was egosyntonic with physicians’ tendencies towards winning and autonomy.  However, over the last 10-20 years, medical schools recognized the negative effects of this tendency and set out to try and train more collaborative doctors.  They found a generation ready-made for this in millennials.

millennials and physician work

Millennials grew up with group projects, team-based learning, and the much-maligned “participation trophies.”  In medical school, team-based care seemed logical and necessary.  Many of us we unaware that what our professors told us was still NOT the norm in medical practice.

Many older physicians view the millennial physician as lazy and entitled, not interesting in working, etc.  What many miss is that millennials are looking for something to work towards, preferably in a team.

We don’t want to win, we want to succeed.  Millennial success doesn’t look like working hard just to have a bigger pile of money, house, or fancier car than our neighbor.  We’ll keep our time, thank you very much, if all you have to offer is money.

Many health systems are fundamentally failing to address this change physician priority.  Millennial physicians are putting an onus on the health system to provide a strategically sound and meaningful vision with which we can align. Yet, the organizations repeatedly fail.  It would be so much easier to buy our complicity – it has worked up until now.

I believe millennial physicians are willing to work as hard as physicians ever worked, but for a reason – not for a paycheck.

I think my supervising partner’s eyes almost fell out of her head when after a mere 8 months in my practice I looked at her and said: “In residency, I was working 25% more hours for 1/6th the amount of money, and I was happier.”  It simply, yet profoundly, did not compute.

evolve or die

Going forward, understanding what younger physicians are looking for will be the key to the success of health systems.  I may be wrong, maybe enough physicians are willing to sell their time so health systems can get into bidding wars and pad upper management’s compensation.

When confronted with the reality of modern medicine, I bailed. I have no interest in working 80 hours a week to support a system in which the care of patients is actually just a means to an end.  Caring for the patient becomes the intermediary goal, the task done to generate revenue.

Well, I should clarify, we document our care of the patient to make money.

The pursuit of winning in the economic morass of the American Hospital-Pharmaceutical complex is getting in the way of our collective success.  As long as we care more about beating our competitor than building the best healthcare system, success will remain out of reach.

A Crisis of Faith at the Crossroads of Sanctity and Commerce

 No other vocation—not even the sacred ministration of religion itself—requires a more constant exercise of the higher faculties of the human mind, or a more earnest devotion of the purer and nobler attributes of the human soul. …  Never suffer yourselves to be betrayed into anything that can degrade your [humanity] or cast the slightest stain upon the bright escutcheon of your honorable profession. - Doctoral Address of Gov. J. Proctor Knott, KY School of Medicine to class of 1890.
Oh, these sweet, noble lies

Those who train future physicians love graduations for the opportunity to repeat exaltations about our sacred calling.  Of course, in the middle of a 36-hour call shift, a speech like this can be a lifeline of validation.  That speech echoing in your head reminds of the purpose of sacrifice.

Yet, the phrase “Healing is an art, medicine is a profession, health care is a business”* continues to be re-quoted. These articles usually discuss the “reality” of healthcare being a business.  They comment on how doctors are increasingly seeking out business training in order to succeed in private practice or leadership settings.

Source: Wikimedia Commons

On the one hand, training programs still hammer the importance of self-sacrifice, humility, and service into young physicians.  Then, they graduate residency directly into a “business system” which, by definition, is trying to get as much profit out of our “sacred art” for the lowest cost.

Sometimes, it feels that training groomed us for exploitation.

 

Externality (n) - a side effect or consequence of an industrial or commercial activity that affects other parties without this being reflected in the cost of the goods or services involved.
doctor and patient outcomes: externalities of the “business of medicine”

As much as “value based payment” is in the news, it is far from mainstream and even farther from delivering its promise.   The healthcare system makes money from providing a large volume of services, not healing or treating.

In the business of providing a high volume medical services, the outcomes of patients only matter if they sue.  The satisfaction of physicians only matter if they leave.  Otherwise, they remain externalities.

Healthcare companies prefer greedy physicians, greed is a value they understand and can exploit to their benefit.  The noble and principled physicians are a nuisance – disruptive.  Those values have no value in the marketplace of American Medicine.

If you can’t bill Medicare for it, it doesn’t exist.

We graduate residency totally unprepared to compete in the arena of business, we don’t even know the rules.  As such, we are also unprepared to protect our own humanity from it, let alone our sacred art.  The current generation of graduating physicians are inheriting a system that has collected a century worth of stains.

Christ Driving the Money Changers from the temple. Source: Wikimedia Commons

The old Catholic hospital saying is, “No margin, no mission.”  It seems now that the margin has become the mission.  Medicine has lost its way at the crossroads of the sacred and the commercial.

The healthcare machine has replaced our once bright escutcheon, bearing the symbols of healing and humanity, with the Madison Avenue designed brands of healthcare delivery.

The moneychangers now own the temple.

“It is easy, when you are young, to believe that what you desire is no less than what you deserve, to assume that if you want something badly enough, it is your God-given right to have it.... I thought climbing the Devils Thumb would fix all that was wrong with my life. In the end, of course, it changed almost nothing. But I came to appreciate that mountains make poor receptacles for dreams. - Jon Krakauer, Into the wild
is medicine too, a poor receptacle for dreams?

I had thought medicine would provide a meaningful, useful vocation in life.  My teachers taught me I should guard my humanity and the sacredness of my profession.

How can you guard these things when the majority have already sold them before you step foot into practice?  Has being a physician become just trading pieces of your soul until you have enough money to FIRE?  Is that the best medicine has to offer?

If  losing my daughter and my first job taught me one thing, it is no one deserves anything.  It seems I have to fight for the kind of medicine I envision, no organization will provide it for me.  Is that the lesson?

Maybe my noble profession is not the direct laying of hands on the sick, but struggling for a new world.  Is a future where the layers of hands and the sick are once again on the same side possible?

[* Dr. John E. Prescott, chief academic officer, Association of American Medical Colleges, quoted in The New York Times, Sept. 6, 2011]

Horseshoes and Hand Grenades

Reason for visit: cough – follow up from urgent care

6 weeks from the end of my intern year, I met B first time.  I walked into the room and saw a healthy appearing 33 year old, dressed in the uniform of kitchen staff from my training hospital .

B had visited a local urgent care twice in the last month for a cough and shortness of breath.  He received azithromycin and a cough suppressant both times.  The second time, the urgent care doctor referred him to the residency clinic so that he could have a more thorough evaluation if it hadn’t resolved.  The cough and shortness of breath had not improved.

I proceeded to do my normal initial patient visit history and physical.  B had a couple of interesting past medical history items.  He was being treated for glaucoma and had had his spleen removed as a child for Idiopathic Thrombocytopenic Purpura.  Interesting, but nothing directly related to his chief complaint.  He denied any history of asthma or other chronic lung problems.

History of present illness

Me:  What has been going with your cough and breathing?

B:  For the past few weeks, I have had an annoying cough and feel increasingly winded doing simple activity.

Me:  Can you describe how winded you feel?

B: well, like on my way over here, I had to stop and rest coming up the stairs in this building.

Now, my clinic rooms were only on the second floor.  I checked his vital signs again: heart rate, respiratory rate, and oxygen were normal.  His lungs were clear, his heart sounds were normal.

An otherwise healthy 33 year old should be able to walk up a flight of stairs, even with bronchitis.  Maybe not with a significant pneumonia, but his vitals didn’t suggest that.

a closer look

I turned and just looked at B.  Up and down, looking for some other clue in his visage that might point me in a direction.  He had short cropped sandy-blond hair, wearing wire-rimmed glasses.  He looked comfortable.  His skin was a bit pale, not hemorrhaging GI bleed anemic pale, but enough to favor a portrait of a Victorian-era consumptive.

I didn’t know much as an intern, but I had learned people who get rare diseases tend get other rare diseases.  I was nonplussed.  Other than the fact that his story just made me worry, I didn’t have a direct line of inquiry.  Just to give myself some time to think, I had my nurse take him up the stairs with a pulse ox, see if that pointed anywhere.

He started up the stairs, oxygen stayed steady, but within a few steps, his pulse shot up to 120.  Something isn’t right here.  I talked to my faculty (still an intern – have to precept every case).  My thought process had frozen, I knew something wasn’t right, but what other tools do I have in clinic?  She helped me out, “how about a chest x-ray and an EKG?”

ORDERs: CXR and EKG

His chest x-ray wasn’t very impressive. I thought maybe his heart seemed a little big for a 33 year old, but the radiologist wasn’t impressed.  His EKG was a different story.

EKG didn’t show any ischemic changes, he had sinus rhythm and no conduction problems.  Those were pretty much the only normal parts.

Axis was confusing, but seemed rightward, P waves were huge, T waves were either inverted or gigantic. He didn’t have obvious hypertrophy, but voltage on his precordial leads seemed moderately elevated. To this day, it was the most bizarre EKG I have seen.  I wish I had a copy.

admit to hospital

I went into the exam room.

“B,” I said, “There is something not right with your EKG.  I am not sure what it means.  It doesn’t look like a heart attack or anything like that, but I think we need to get you to the hospital to figure out is going on.”

B seemed neither relieved nor worried, “Okay.”

I called my fellow on-call intern and the chief resident.  Presented the case and arranged for B to admitted to the hospital.  The work up began in earnest.  Most favored a pulmonary embolus as the cause of B’s symptoms.  The team ordered the requisite CT Angiogram of the chest.  The read came back.

NO pulmonary emboli identified.  pulmonary arterial trunk measures 4.5 cm, highly concerning for severe pulmonary hypertension.

The echocardiogram the next day confirmed that B did indeed have severe, end-stage pulmonary hypertension (PH).  Right ventricular hypertrophy. The cardiologist and pulmonologist were called in.  The work up provided no treatable cause of B’s PH.  The label became “Idiopathic,” which is doctorspeak for “we don’t know.

Henry Vandyke Carter [Public domain], via Wikimedia Commons
When the cause of a problem is unknown, treating it very effectively becomes rather difficult.  The cardiologist scheduled a heart catheterization for an arterial dilation test.  This was to determine which therapy might be appropriate.

His pressures were too high to complete the test safely.  The cardiologist aborted the procedure.  He arranged transport to the nearest university medical center.  B needed to be on a transplant list.  33 years old.

good catch, man!

My classmates congratulated me on my “good catch.”  A well appearing man walked into my clinic with a rather benign complaint and I started a work up that caught a zebra.  We rapidly identified a diagnosis, involved the correct specialists and provided, I do believe, excellent care.

I went to see B in the hospital the day before his transfer out of the city I trained in.  He was cautiously optimistic and glad to have an answer and to be getting to where he needed to be.   He thanked me.

I asked him if he had family coming.  He said his parents would meet him at the university hospital and his sister was flying in from out of state.

“That’s good,” I reflected, “Family is important when you are going through something like this.” We shook hands and said goodbye.

Nothing puts swagger in an intern’s step like catching a zebra where one least expects it.  I felt pretty damn good.

when your best isn’t good enough

One of my favorite things about traveling around rural parts of the country is picking up rural aphorisms.  One that I grew up on in my household was, “Close only counts in horseshoes and hand grenades.”

Two weeks after B left our care and hospital, I went into his chart to show a colleague his EKG.  The computer attacked my vision with the notice:

YOU ARE ENTERING A DECEASED PATIENTS CHART. 

I sat back stunned.  We came close, but medicine isn’t horseshoes or hand grenades.

Later that day, I talked with my fellow intern who cared for B in the hospital.  I let him know the news, he had a similar reaction.  We had felt so good about the care we had provided to B.  We were at the top of our intern game and yet, he died.

humility is a punch to the gut

Did we do anything wrong?  I certainly don’t think so.  Diagnosis, treatment, transport to appropriate care in a timely manner.  All done better than average, I would argue.  We were proud, especially for a team of family medicine residents and interns.

By Rama – Own work, CC BY-SA 2.0 fr, https://commons.wikimedia.org/w/index.php?curid=3632261

By the stars aligning, my fellow intern’s significant other was an ICU nurse who moonlit in the university ICU.  On her next shift, she asked around.  It turns out B was admitted there, kept in the ICU for monitoring.  One night, shortly after his arrival, he went into ventricular tachycardia, an unstable cardiac rhythm.

The ICU team attempted to revive him for 2 hours through the use of every life saving medication and procedure they had.  Codes are normally called after 30-45 minutes.  He was 33 years old.

reconciling polar opposites

Sitting in my bed one night, staring at the ceiling, I talked about B’s death with my wife.  I don’t talk about patients with my wife often.  So, when I do, she knows the patient affected me deeply.

Usually, when someone dies or there is a bad outcome, I am able to derive a lesson for honing my art.  Next time, I will do XYZ, and it’ll go better.  I make sense of the loss through striving for improvement.  It helps add meaning.

What happens when you did better than would be expected and it still goes south?  “Nothing we could have done better, that is just life in medicine” seemed like a poor salve for my wounds.

Overtime, I thought back to the last conversation I had with B.  His family was coming to see him, they new the diagnosis by the time he died.  The grief doesn’t disappear because of knowledge, but every removed uncertainty helps, I think.

Most importantly, I believe they had a chance to see their son and brother before he might have suddenly died of a cardiac arrest.  That was a gift I gave him and his family: some answers, and some time.  We can’t always save, but we can always heal.

the dead are never gone

Having now gone through my own loss, my perspective on B’s story has evolved.  Families carry the care and comfort we give to patients who die, just as they carry the memories and lessons of their loved one.   This can be a blessing, and it can be a burden.

If we can give patient’s families memories that their loved one’s time under our care was full of support, strength, and understanding – it can be a great gift.   It is invaluable in their grief and healing.

Anger is an all too easy trap for grief.  It is a natural and normal part of the process, but it can be seductive.  Anger is often easier to feel than the unending sadness or permanent loss. Anything we do as healers that makes the transition from anger to the other parts of grief easier, is of immeasurable value to patients and their families.

I now know this all too personally.  Death is not an option, only a matter of time.  Yet, we as human beings, and especially as physicians, have the power to meet it in different ways.  We can meet death with love and the support of family and community, it can strengthen the bonds between those who are left behind.

As physicians, we have the power to facilitate that journey.  It is a terrifying journey, people need guides.  We have that power, if we choose to use it.

If we choose to help people meet death on their own terms, we choose to help them know life in the richest way possible.

Modern Medicine is Mindlessness

“If while washing dishes, we think only of the cup of tea that awaits us, thus hurrying to get the dishes out of the way as if they were
a nuisance… [then] we are not alive during the time we are washing the dishes. In fact we are completely incapable of realizing the miracle of life while standing at the sink. If we can’t wash the dishes, the chances are we won’t be able to drink our tea either. While drinking the cup of tea, we will only be thinking of other things, barely aware of the cup in our hands. Thus we are sucked away into the future – and we are incapable of actually living one minute of life.”
― Thích Nhất Hạnh, The Miracle of Mindfulness

can mindfulness and modern medicine coexist?

Often, especially when I practiced primary care, I felt the need to accomplish a task to get to the next one.  My task-oriented nature repeatedly stole my present and gifted it to the future.

Prescription refills, prior authorizations, signing documents that have nothing to do with patient care – all exploited this weakness.  I was always to trying to wash the dishes to have clean dishes.

I could not seem to live a minute of life while at work.

Joshua Tree NP – NPS Public Domain

After I had decided to quit my job, I went on a solo grief retreat in the Mojave Desert.  Among the joshua trees and cinder cones, I finally returned to the present.  I read the Miracle of Mindfulness for the first time.

 

 

While reading, I had a revelation: the basic structure of modern medical practice sabotages mindfulness.

working on self-compassion

In current practice, organizations expect physicians to welcome any and all intrusion into their work in the name of patient care.  However, increasingly non-patient centered tasks fall into this category.  Seemingly, the system has learned how to manipulate our value system.  Suddenly, anything anyone wants done is a reason to interrupt.

Sadly, even before I lost my daughter and things took a turn for the worst, I felt an intense pressure to try to fix what I found unpalatable in my worklife.  I put the pressure for resolving my discontent with the system entirely on my shoulders.

Now, I am no accomplished mindfulness practitioner.  In the Miracle of Mindfulness, Thich Nhat Hanh discusses the relative ease of being mindful alone on a walk in the woods rather than in company.  I should not have realistically expected myself to find a way to mindfulness surrounded by the least mindful workplace I have experienced.

every system is designed to achieve the results it produces

It is unfair to expect a novice in mindfulness to advance as a practitioner in such an environment.  Shift work has helped relieve me of this burden, an under-appreciated reason for its increase in popularity.  I can focus on medicine while at work, and focus on washing the dishes when not.

I hope someday I will be mindful on the scale of minutes or seconds.  On the other hand, isn’t that too much to ask of a novice?  Yet, that is what our system demands of doctors. Burnout is the natural outcome, not an occasional, unfortunate byproduct.

Nonetheless, hospital executives seem to think that a half-day mindfulness seminar is good enough to prevent physician burnout.  A lecture and some breathing exercises checked the box, no need for changes to systemic processes or organizational culture.

Thich Nhat Hanh- Public Domain

“Feelings, whether of compassion or irritation, should be welcomed, recognized, and treated on an absolutely equal basis; because both are ourselves. The tangerine I am eating is me. The mustard greens I am planting are me. I plant with all my heart and mind. I clean this teapot with the kind of attention I would have were I giving the baby Buddha or Jesus a bath. [emphasis added] Nothing should be treated more carefully than anything else. In mindfulness, compassion, irritation, mustard green plant, and teapot are all sacred.”
― Thich Nhat Hanh, The Miracle of Mindfulness

welcoming, recognizing, and treating ourselves equally

Part of learning to be in the world is coming to terms with our own frailties.  At first, I viewed my current position of a traveling critical access doctor as a transition until I found a new permanent practice.

I had phone interviews for perhaps a half-dozen practices.  A funny thing happened: by the end of every interview, I no longer wanted the job.

After having this epiphany, I eventually accepted I currently don’t have the level of accomplished mindfulness to face the mindlessness of modern medical practice.  In the middle of a busy clinic or call day, I just don’t have the mental discipline to wash the teapot like a baby Buddha or Jesus.

I then asked myself a second question, “Should I want to?”  I am still working on that answer.  So far, in my grieving state, I am just not willing to work so hard just to be able to survive the barrage of dysfunctional practices that are currently de rigueur.

An opportunity to not only survive medicine, but actually thrive, may someday yet appear.  We, as physicians and patients alike, can only hope.