Can Physicians Resist? Or Only Vote with Our Feet?

The Culture of Medicine values orthodoxy.  The requirements for getting into medical school are extremely rigid and in no way value aspects of an applicant not easily testable or quantifiable.

Indeed, the various hoops, tests, and checked boxes of getting into medical school seem more designed to weed out renegade, innovative, creative types than to assure a high caliber of applicant.

They select for the correct quality of applicants, not the high quality of applicants.

Medical school admission seems primarily designed to identify individuals who are adept at learning the rules of the game and then driven to win the game.  Anyone who questions the game is summarily excluded.

As a cadre, physicians are poorly equipped to resist the Hospital-Pharmaceutical Complex.

We are acculturated to shrink our purview to the smallest area possible. This makes it easier to control all of its aspects, which soothes our control-oriented personalities (also selected for in the admissions process).  However, it also dilutes our influence and robs us of seats at the decision-making tables.

Yet, many, if not the majority, of us are extremely dissatisfied at the state of American Medicine. I have written plenty about this.  If we are so dissatisfied, why aren’t physicians across the country rising up and demanding change?

We don’t know how to Resist

Physicians spent their high school and college years languishing in libraries and study halls.  We didn’t go to trainings in direct action.  In residency there are no rotations in “managing organizational change.”

We are so focused on getting the “right” answer, we have rarely had the opportunity to demand those asking the questions defend their choice of question.  Give physicians a set of rules to a game, and we fight tooth and nail to prove we can be best.

Ask a group of physicians whether or not the game is just, worth playing, or if the rules should be changed and we just stare blankly back at you. Those questions have no winners, it does not compute.

For sure, we are raising our voices at higher rates than we ever have in the past.  Yet, the machine keeps jugging along.

Debt, Competition, and Greed

Maybe it is as simple as too many of us are debt-indentured.  The vast majority of us start with $200k+ in debt in our early thirties and then add a mortgage and often some other consumer purchases as well.

Are so many of us permanently debt-indentured to the point where all we feel we can do is just keep our heads down, pay off our debt, and get out?

I slammed my head against the wall for 12 months in my first job. I tried incrementalism from the inside.  It was terrible, and when tragedy hit, I didn’t have the stomach for it anymore.

No one ever articulated what we were working towards. What change were we really trying to make?

Of course, I learned no one was trying to make change.  They were just trying to make as much money as possible, for the system, and then for themselves.

My partners just agitated for more money for less work with a better schedule without the EMR. Their passion had withered to greed and self-interest, cloaked in the name of patient care.

Effectively, they were still applying to medical school.  They were just just trying to win the game.

They didn’t care that the game was corrupt and the purpose of the game was completely divorced from its original purpose.

Or, has this always been medicine?  Has medicine always been a dichotomous beast of greed in the name of helping others?  Test, cut, prescribe until we are wealthy enough retire to a golf course community?

Have those who couldn’t hold their noses any longer always just left?

Is that our only option, to vote with our feet?

Is There Another Way?

At least in rural medicine, it seems as though all physicians can do is vote with their feet.  It seems so dissatisfying to have that left as our only option.  Also, as the problems of the healthcare industry are truly national in scope, there are few places left to run.

No real competition for physicians exists because the industry leaders have all embraced the same models which perpetuate burnout. As we are squeezed more and more to “produce,” our time and energy doesn’t allow for resistance and fighting for change.

Normally, it is the young and energetic who push for change.  The newest generation of doctors emerges into a field where all their excess energy must be tapped towards getting out from under a debt load. One reasonably measured in fractions of a million dollars.

We debt-laden young physicians have nothing left at the end of the day to offer the fight for change.  As such, our voices are largely silent in the national arenas, except of course on the impotent platforms of social media echochambers.

Instead, healthcare “industry groups” and our National Academies usurp the right to speak for us.

Our supposed representatives mostly seem hell bent on protecting or increasing reimbursements for their loudest members, not on making doctoring a fulfilling vocation again.

Surviving the healthcare industry has sadly become our goal.

I certainly hope something or someone comes along as a realistic option to fight for change, but my hope is mostly vestigial.  It is a mere remnant of an idealism and passion which seem a bygone memory.  Pretty soon, the only place left for our feet to go will be out of medicine entirely.

Honestly, I don’t think I am smart enough, connected enough, nor strong enough to find this other road.  I would love for someone to show it to me, though.  I would love to follow someone on that journey.

I do not believe I have the strength or skills to lead anyone in hacking a path out of the wilderness we are in.  Besides, I have proven myself to be more than content with wandering.

After all, the wilderness is a fine place, we could use more of it.

Rural Medicine: Reaching the Limits

The world of Critical Access Medicine is unknown to most physicians.  Lots of reasons exist to explain this.  Most physicians come from rather privileged backgrounds – read urban/suburban/well-educated.  Outside of vacation, their exposure to Rural America is very limited.  They simply do not know what is out here.

Medical training largely does nothing to address this lack of familiarity.  In general, medical training concentrates physicians in large cities right at the time time they are beginning to have families and start careers.  This makes moving somewhere else after training even less likely.

The culture of large teaching centers glorifies the specialist and high-tech, high intensity medicine. Physicians who teach in these centers often denigrate “community practice” as somehow behind or inferior.  Moreover, physicians who practice in urban areas often cite the lack of resources as an impediment to good care.

I have met physicians who have all or some of these biases against rural medicine.  The lack of resources, however, is absolutely a real issue.  I run into it on a regular basis.  I understand other physician’s frustration.

Multiple times on my last shift, I ran headlong into barriers to providing care.

Making Do

On a recent shift, a woman came in with the complaint of weakness and slurred speech.  Upon seeing her, I immediately called a stoke alert.  I do not work in any hospitals with a neurologist, let alone a “stroke team.”  Some have telemedicine robots so a stroke neurologist can evaluate a patient remotely.

This hospital does not even have the robot.

In most Critical Access Hospitals, lab and X-ray are not in house until you call them.  So, we worked on getting things started: drawing blood, placing IVs, etc.  I did an NIH stroke scale, 11.  The score met diagnostic criteria to consider tPA, if her other factors didn’t disqualify her.

Finally,  tech X-ray tech arrives.

“I need a stat CT of her head.” I initially received only a blank, sheepish stare in response.

She looked at me, at the patient, and back to me.  The X-ray tech leaned towards me and asked under her breath, “How how much does she weigh?”

The bed scale registered an astounding 472 lbs.

I turned to the X-ray tech, “That is above your scanner limit, isn’t it?”  She nodded up and down.  I knew the next closest CT scanner was 30 miles away, the hospital is slightly bigger (they have surgery capability and visiting specialists).

“Call Otherton and see what their CT scanner can hold.” The X-ray tech ran off to call and ask.  The one room ED was milling with people –  family, EMTs, nurses.  None of them doing much at that point, save for the lone nurse struggling to get an IV in the patient’s difficult habitus.  This was the most exciting thing to happen in this down for weeks.

After a few minutes, she returned.  “Their limit is lower than hours.”

“Of Course it is.” At this point, I had already accepted this is not going to go my, nor the patient’s.  I grabbed the phone to call the nearest stroke center, almost 3 hours away.

The long distance consult/transfer conversation follows a script.  Patient’s name, brief past medical history, brief story of what has happened.  In the case of a stroke, special attention to presenting physical findings and last known normal is the expected.  Then, I get to the meat of my call:

“So, the real struggle right now is she is well over the weight limit for our CT scanner and the next closest CT scanner is 30 minutes away and apparently has a lower weight limit than ours.”

Then, I heard something I have never heard from another physician on the consult line.  The stroke neurologist offered a simple line.

“I’m sorry.” This was quickly followed by, “Yeah, let’s just get here as fast as we can.  She is already out of the tPA window, we’ll finish her evaluation here.”

We sent her by ground ambulance as quickly as possible.

We Don’t Have That

The next day, an ambulance arrived with a 40s male, actively seizing for 20-30 minutes after the police arrested him.  No IV’s were placed in the field, he is completely unresponsive.  We quickly placed an IV and began the rounds of diazepam.  Finally, after three rounds, his seizure activity stopped.  He was still unresponsive.  GCS of 7, even after watching for any post-ictal improvement.

I have learned at this point it is more effective to ask for certain items rural EDs keep in bundles rather than what you would, ideally, prefer.  So, I didn’t as for my preferred induction agent, paralytic, etc.  I just asked them to bring their RSI kit, video laryngoscope (if they have one) and regular laryngscope.

“While we are getting ready to intubate, can someone get some IV keppra ready.”

“We don’t have that.” I am told.

“Fosphenytoin?”

“Umm, I don’t think so.”

“What other IV anti-epileptic medications do you have other than benzodiazepines?”

“I don’t know, maybe ketamine?”

Practicing medicine in a Critical Access setting is not a smorgasbord.  It is an 8th grade cafeteria line.

You can have whatever you want as long as it is Salisbury steak.

I proceed to intubate.  Afterwards, he was thankfully easy to bag and maintained end tidal CO2 and Oxygen levels in desirable ranges.  I asked if we have a ventilator.  An eager EMT piped up.

“Oh yeah, it is right over there.”  He pointed to a machine sitting on a crash cart with a big red sticker on it, “Out of Service.”

“Oh, I guess not.” He sheepishly admitted.

“Okay, bag him, make sure not to hyperventilate.”

Luckily, we have already called the local Medevac crew for critical care transport. They arrived and hooked patient onto their ventilator.  Carefully, they moved him with all his the sedation drips and IV fluids to their stretcher and flew him off to somewhere with an ICU.

Somewhere with a functioning ventilator and some damn Keppra.

I looked around that the remaining EMTs and nurses.

“Well, that could have gone worse.”

Why Do This Job?

I have talked to a fair number of EM residency trained ED docs and I often get the response of, “Oh, practicing out there would terrify me.”

I have no MD back up, no specialist support other than what can be obtained over the phone.  The EDs are often minimally staffed and under-provisioned.  On the other hand, my shifts are rarely so eventful as this.  Usually, it is Urgent Care level work ups. Often times it is downright boring – 24 hours without a patient sometimes.

But, that is the thing with an ED, anything can show up, even if it usually doesn’t.

I think a lot of quaternary care center trained physicians bristle at the resource limitation.  “I just wouldn’t feel like I am doing a good job.” is another statement I have heard.

I actually understand these concerns, no one likes to feel like they are providing less than the best care.  My response is simple.  The patients I see can’t call 911 and get dropped off at a Level 1 trauma center.  They are 2.5 hours from a level II, 30 minutes from a level III, minimum.

You can only take care of patients where they are.  Patients in Rural America need medical care just like patient in Urban America, but that isn’t where they are.  It’s called Critical Access for a reason.  Doing what is possible when you must is often more meaningful to the patient as doing everything because you can.

Time is of the essence in so much of what we do.  Waiting 20 minutes for a BLS ambulance to arrive and then driving another 30-45 minutes to the next closest Emergency Department could have meant serious brain damage for the man that man.

Could I offer him everything?  Of course not.  But I offered him a hell of lot better than 30 minutes of seizing in ambulance.

The famed bank robber Willy Sutton once answered the question, “Why do you rob banks?” with a simple, “Because that’s where the money is.”

I suppose, in the end, my answer is just as simple.

Why do I do this job?  Because it’s where the patients are.

Featured Image: The British Army in the United Kingdom 1939-45 Soldiers from 24th Battalion, Hampshire Regiment scale an obstacle during ‘toughening up’ training in wintry conditions at Wateringbury in Kent, 20 January 1942.

 

 

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.

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.

 

 

 

 

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.

Good Money after Bad

when is a relationship worth salvaging?

My second clinic manager in my first job (he left about 3 months before I did) told me once, “Spending more money on a bad investment doesn’t make it a good investment, just a more expensive bad investment.”  So, the trick is knowing when putting any more effort into a relationship, job, investment, etc. is just making it more expensive.

The problem is, if you follow Boglehead logic, timing a market opportunity is fraught with risk.  The likelihood of bailing too soon, or staying too long, is high.

In my first job, I quickly came to the realization that I was throwing time and energy into a black hole of dysfunction and left.  Now, six months out, I am trying to figure out how much I damaged my relationship with Medicine by staying so long.

I increasingly recognize that I hold the Modern Institution and Culture of Medicine personally responsible for how I feel about my career. The problem is – they have no personhood.  They don’t care how I feel.

I have not absolved my ex-partners of their complicity in what happened, but I also recognize that ignoring the systemic processes and blaming individuals risks repeating the past.

If you don’t know why you end up in abusive relationships, you are doomed to keep falling into them.  Attempting to prevent myself from doing so, I have run head-on into my own smoldering anger at the Institutions of Medicine.  Can I repair this, or does my relationship with Medicine have a expiration date?

can you even have a relationship with a machine?

  The current iteration of medicine treats medical care as an assembly-line delivering medical procedures, treatments, medications and consultations.  Can a physician actually have a relationship with this?

Healthy relationships have boundaries, reciprocity, and are based in genuine affection.   Bureaucratic assembly lines don’t have any of those.

I think in the past, physicians owning their own practices and having more professional autonomy buttressed this imbalance.  Indeed, working as a traveling doctor has allowed me to have full control over my schedule and clinical autonomy.  Putting our relationship on ice for a couple of years seemed the only way to save it.

anatomy of a breakup

Medicine and I had a heady first few years.  I spent the night at her house at least a few times per week.  When she called in the middle of the night, I was always there to pick up.  I spent more time with her than with my wife, and I put more time into my relationship with Medicine than any other.

I thought that if I put in the time now, I would be able to cash in after residency, get some relational reciprocity.  I’d put in my effort, now Medicine would help take care of me for a while.

WRONG!

Inuidia – Envy

Every time I tried to pull back, Medicine tried to suck me in harder.  Crises that were out of my control seemed constant.  Medicine was jealous of my newfound interest in anything else.

I bailed, put some physical distance between us.  I still go and visit her a few days a week on average, but I don’t pick up her calls anymore when I’m home.  She doesn’t get to meet my friends or family.  It is an uneasy relationship, but not broken yet.

can our relationship be saved?

The thing is, for a short period of time in residency, I actually did love Medicine.  I was exhausted, but felt I was doing something worthwhile.  Sometimes, in the middle of a shift on the High Plains, I still touch those feelings.  I catch a glimpse of professional satisfaction and efficacy.

want to love medicine, I really do.  The problem is, machines don’t love you back.  How do I forgive the machine for hurting me so deeply when it is not even aware?  Can the bonds be repaired?

Or, am I the idiot for thinking of this whole thing in terms of a relationship?  Machines don’t love, they cannot be in relationship.  Is Medicine just a job, no longer a calling?  Can it just be that?  Will Medicine be comfortable with being just a job, or will it always strive to be the most important thing in my life?

Only time will tell.  Maybe we’ll evolve together, find a new equilibrium.  For now, the uneasy visiting routing continues.  Perhaps, I’ll even get over my anger and learn how to love the one I’m with – eventually.

And if you can’t be with the one you love, honey
Love the one you’re with. – Stephen Stills, of Crosby, Stills, and Nash

A Tale of Two Medicines

Bias in Medical Practice

If you have read some of my other posts, you know I have an interest in the culture of medicine.  More specifically, how cultural biases in medical training and the culture of medical practice affect the care of patients.  I think one of the starkest examples of this is the reaction to deaths from rofecoxib (Vioxx) and those from opiate pain medications.

tale one: rofecoxib

Rofecoxib is a non-steroidal anti-inflammatory drug (NSAID) pain medication.  Ibuprofen and naproxen are common NSAIDs.  At high, sustained doses they have a range of negative side effects – GI bleed, kidney damage, hypertension, heart disease, etc.  Rofecoxib was biochemically more specific to inflammatory pain. Therefore, it was a new generation of NSAID with supposedly fewer side effects.

Rofecoxib was on the market from 1999-2004.  The FDA pulled it from the market after discovering evidence that it increases rates of heart attack.  Doctors prescribed it primarily to treat arthritis pain, which is more common in the elderly, who are also more likely to have heart disease.  It turns out, a deadly combination.

Hand Arthritis – By Internet Archive Book Images, via Wikimedia Commons

“Dr. Graham and colleagues estimate that during the five years Vioxx (rofecoxib) was sold in the United States, it caused between 88,000 and 140,000 excess cases of serious heart disease. Based on national statistics of heart disease and deaths, the researchers estimate that close to half of those cases, or 44 per cent, would have resulted in fatalities. This means anywhere from 39,000 to 61,000 deaths in the United States could be linked to Vioxx.” – Daily Globe and Mail

tale two: opiates

Opiates are a class of pain medications originally derived the opium poppy.  The category now also includes a number of synthetically created compounds designed to act on the same biochemically receptor.  These include oxycodone, hydrocodone, fentanyl, heroin, tramadol, etc. I am sure the current opiate epidemic is not news.   People are dying at an unprecedented rate from opiate overdose.

Like NSAIDs, opiates have a wide range of known side effects.  These range from constipation and urinary retention to addiction, respiratory depression, and death.  Let me clarify here: addiction and death from respiratory depression have been known complications from opiate use for over a 100 years.

In fact, roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them and between 8 and 12 percent develop an opioid use disorder (addiction). This is NOT new data coming out in research papers.

In 2017, 63,617 people died from drug overdoses. At least two thirds of those were linked to opiates.  Almost as many people who died from rofecoxib over FIVE years died in ONE year from opiates.   Many will say that most of those are from illegal use of the substances, which is true.

However, in 2008-2009, a study showed that 86% of injection drug users started with prescription opiates.  That means that conservatively, around 36,491 of those deaths can be traced back to prescriptions given by a physician or healthcare provider.  We don’t even have good data on how many people are currently struggling with addiction (the corollary to heart attack in this comparison).

To reiterate, addiction to opiates has been a KNOWN side effect of treatment for over 100 years.

Rofecoxib and Opiates Kill People

Merck eventually settled its Vioxx (rofecoxib) liability for billionsMany states are suing Pharma Companies for misleading consumers and doctors about the safety profile of their drugs.  Yet, doctors didn’t know about the heart disease risk when prescribing reofecoxib.  However, doctors did know addiction and death were side effects of opiates at the time opiate treatment was increasing.  Nonetheless, we kept on prescribing them.

Again: rofecoxib is a pain medicine killed up to 61,000 people over a 5 year period from heart attacks.  Opiate pain medicines have killed many times that over a 5 year period and almost as many in 2017 ALONE.  Rofecoxib was rapidly removed from the market to protect patients.  Yet, ALL of the opiate pain drugs remain on the market.  What explains this difference in reaction?

to americans, addiction is a vice, not a disease

The main difference in these two situations is our societal wide lack of compassion for people struggling with addiction.  Don’t get me wrong, people in the throws of addiction are often very unpleasant people to care for.

Then again, many schizophrenics in the throws of their disease are very unpleasant to care for.  However, we don’t blame their disease on their character.  We recognize that they are sick and need treatment.

I can’t count how many times patient’s have said to me, “Well, those people aren’t using the medicine correctly,”  when I am describing the risks of addiction and death.  The implication is that I could never be one of those people because I have a stronger character, am more educated, am God-fearing, etc.

Guess what, people?  Addiction can and does happen to anyone.  You are not immune.  Just like heart disease, some people are at higher risk (those with histories of sexual abuse, PTSD, depression, anxiety, etc).  No one is immune.

addiction is a terrible disease

Moreover,  I have cared for people with heart attacks and people with addiction.  Heart attacks are scary.  They can be personally devastating.  Whenever someone dies, it is very, very sad.

However, heart attacks do not leave entire families broken and scattered.  Babies, addicted to opiates from birth, are not struggling through withdrawals in NICUs around the country because of heart disease .  Whole communities are not in a constant state of grief because of heart disease.

Yet, people with heart disease are treated as sick people and people with addiction are treated as bad people.  This continues to happen everyday in this country.

when you find yourself at the bottom of a hole, the first thing to do is stop digging

It is time we stop digging.  I am not proposing we ban the use of all opiates. Yet, as long as we are unaware of our biases toward the risks of addiction and treatment with opiates, we will be doomed to repeat the cycle.

 

Millennial Physicians Didn’t Start the Fire

millennial physicians

If you google “millennial physicians,” the first result is the article “Do We Have  Millennial Physician Problem?” I have been rereading this article for a few months now, trying to decide how I felt about.  In it Dr. Jain feigns an attempt at presenting both sides of the question, however only provides evidence (and it is anecdotal) of the thesis that we DO have a millennial physician problem.

[A] classmate relayed the story of a medical student, Elizabeth, who routinely failed to pre-round on her patients in the early morning during her sub-internship–as is customary to ensure that patient health has not deteriorated overnight–because she didn’t feel like it was always necessary.

What about the years of clinical standards supporting pre-rounding as a means of protecting patient safety?

She wasn’t convinced that it was always necessary.

……

Do we have a millennial physician problem?

I’m not sure.

……

And it’s hard (and unfair) to judge an entire generation by a few outlier cases. Every generation of physicians has its share of bad apples who just don’t get it.  -Sachin H Jain, full text available here

I have run into this generational divide between older physicians and millenial physicians personally, so I can’t help but have a reaction to this article and its prominence.  Firstly,  no one is discussing Baby-Boomer Physicians or Gen Xer Physicians as a monolithic cohort affecting medicine.  Yet, much of the responsibility for many of the current disturbing trends have emerged under their watch.  Millennials have only just arrived to the dumpster-fire of modern healthcare.  And as Billy Joel said – We didn’t start the fire.

No, we didn’t light it, but we’re trying to fight it – Billy Joel
disturbing trends in modern medicine
  1. Opiate Epidemic – the vast majority of the fault of the beginning of the opiate epidemic lies with a Hospital-Pharmaceutical Complex.  Physicians have been at minimum complicit in this, and at worst – many have been acting as drug dealers.  Again – it predates Millennials.
  2. Physician Suicide and Isolation – “A systematic literature review of physician suicide shows that the suicide rate among physicians is 28 to 40 per 100,000, more than double that in the general population.”  This is largely related to stigma and access to lethal means.  Stigma is created by culture.  The Boomer and Xer love of “physician autonomy”  helps isolate and stigmatize those physicians who are suffering.
  3. Health 2.0 – Medicine As Machine – “Instead of ceding authority to the guild of paternalistic physicians, we now cede to endless bureaucracy — the swelling ranks of the administrative technocracy, with its faceless protocols and algorithmic click-boxes codified in that glorified cash register, the electronic health record. We now treat a computer screen while our patients are reduced to 0’s and 1’s in the Medical Matrix.” – Zubin Damania (Zdog, MD).
  4. There are obviously more – but you get the point…
those who live in glass houses…

Are millennial physicians as a group perfect and amazing? No, we are flawed and human, similar to all other generations before us.  We are just flawed in ways that often create conflict with the generations before us.  We were raised on evidenced-based medicine.  When we are told, “This is the way things are done,” and given no evidence as to why and look around at the House of God burning down, we have to respond, “Well, maybe that isn’t such a good way if this is where it got us.”

Are we more interested in our own happiness than those physicians before us?  Probably.  On the whole, I think that is a positive.  The most important tool a physician has is her own mind and acumen, shouldn’t we spend a lot of time caring for and maintaining that tool if it is going to continue to serve us and our patients? I think so.

At the extreme, the focus on “me” probably does lead to selfish behavior on the part of some of my cohort.  But egos and selfish behavior are nothing new in medicine, the stories of the surgeons of old throwing instruments and dressing down OR staffs are legendary.  I have also seen many an older physician conflate the care of “their patients”  and their own ego – to the detriment of both.

oh! the humanity!

We are all human, we all have bad days.  The expectation of invulnerability and the wearing of overwork as a badge of honor contribute to the medical culture that is toxic to many.  The idea that you haven’t given enough if you have anything left to give leads to toxic cultures.  I should know, I just escaped one.

On the whole though, I do think that millennial physicians came to medicine to help serve and heal.  Now that we are entering the physician workforce in more and more significant numbers, the reality we encounter is less than impressive.  We like teams, we like community, we want to have each others’ backs.  We WANT to make things better – together.

the tribe vs the lone ranger

What I have found, and I think a lot of my cohort, is a medicine designed around individuals, not communities.  I was excited to join the community of practicing physicians.  What I found was not a community, but rather loosely affiliated individuals each grinding away in pursuit of their own individual accomplishments – research, money, prestige, etc.

Each generation has its own flaws and sins, its own strengths and virtues – these can be harnessed to complement each other.  We as physicians could choose to act as a community.  We could do this not only to protect our privilege (as seems to be the AMA’s primary purpose), but in service of a goal larger than ourselves and our bottom lines – to finally give America the healthcare system it deserves.

Or, we can continue to wear our overwork like badges of honor, snipe each other, engage in turf battles, whine about decreasing reimbursement – all while the machine churns along quietly and incessantly, until it is too late.  But then again, maybe should we just let it burn and start over?

 

Does the H&P Impede Care of the Chronically Ill?

History and Physical (H&P) – The Cognitive Structure of Medical Training

Medical training generally works like this:
  • 2 Preclinical years – this is the “drinking out of a fire hose,” where you just try and cram as much as possible into your brains.
  • 2 Clinical years – this where you are supposed to learn how to think like a doctor, get exposed to all the different specialities, and decide what to do for the rest of your life (don’t worry – no pressure).
  • 3-5 Residency years: learn the tools, procedures, and knowledge specific to your specialty and how to apply them.
What is the H&P?

The H&P is the cognitive form that medical training drills into you starting at the end of our preclinical years.  All those questions that your doctor asks you that you don’t understand why she is asking them – they are from the H&P.  It generally looks likes this:

Chief Complaint – One word/phrase about why you are there

History of Present Illness (HPI) – paragraph about what has been going on

Review of Systems (ROS) checklist of symptoms from body systems not directly related to the HPI

Past Medical/Past Surgical/Family History medical events in your personal or your family history

Social History – Smoking/other drugs/alcohol/ maybe profession and/or marital status if someone is being thorough

Vital Signs/Physical Exam/Objective Data – the laying of hands, the stethoscope, and any lab/X-ray data.

Assessment/Plan – What the doctor thinks is going on and what she plans to do about it

The H&P is very useful for communicating a patient’s story between doctors, its original purpose.  It is also useful for helping us remember to ask/do certain things.  Unfortunately, it has also become the basis for the billing of non-procedural physician work.  Physicians base their billing on the documentation in their H&P.  No longer just a communication tool, the H&P has become a billing sheet.  Nonetheless, even as a communication tool, it is limited.

The H&P does not demand this kind of information:
  • Recently laid off
  • Homeless
  • Non-literate
  • Going through a divorce
  • Friend just got diagnosed with cancer
  • Sexually Abused as a child
  • Closest full-service grocery store is 5 miles from house requiring a 1.5 hour bus trip with 3 transfers

Source: https://nonprofitquarterly.org/2017/11/28/nonprofit-says-communities-not-doctors-must-lead-improve-health-outcomes/

Some would say all of the above is social history.  A reasonable assertion, but Social History is culturally undervalued in medical training – it is not “hard medical fact.”  Also, per billing regulations, social history is worth significantly less than ROS or Physical Exam points. It is literally worth less money to ask about the aspects of a patient’s life that most affects their health (see Figure).  The social determinants of health deserve, and will probably get, an entirely separate post.

 

the h&P assumes a certain level of baseline health

The very nature of the headings: Chief Complaint and History of Present Illness create the assumption acute illness.  Especially in primary care, this is often not the case.

Currently, even in acute care settings, most problems are actually an exacerbation or destabilization of chronic disease.  The very structure of the H&P helps blind us, and by extension patients, to this fact.  The H&P helps place our brains into the cognitive trap of trying treat chronic problems as acute ones.

In the middle of a rough primary care clinic day, I often wished I could have used the Chief Complaint of “Same Shit, Different Day.”  I don’t mean to invalidate patients’ suffering – but it is CHRONIC, not ACUTE.  It has been going on for YEARS and will not improve when treated as an acute problem. Yet, that is what physicians are programmed to do.  At a system level, that is what we are forced to do.

The “explanatory models approach,” which is widely used in American medical schools today, as an interview technique….that tries to understand how the social world affects and is affected by illness. …. We’ve often witnessed misadventure when clinicians and clinical students use explanatory models. They materialize the models as a kind of substance or measurement (like hemoglobin, blood pressure, or X rays), and use it to end a conversation rather to start a conversation. – Anthropology in the Clinic  By Arthur Kleinman and Peter Benson

THis tendency has been recognized before

Arthur Kleinman, MD has been trying since the 1970s to get medical training to build more of the psychosocial aspects of patient’s lives into the basic cognitive framework we use in treating patients. He popularized “explanatory models” as a way to delve into the patient’s psychosocial world. Explanatory models are popularly taught in US Medical Schools, but they often fall flat (see quote above).

Personally, I saw some of that influence in my medical school, but it was presented perfunctorily, once or twice.  Whereas the basic formulation for the H&P is drilled into you on every rotation. By the end of medical school, it would be like forgetting how to tie your shoes. Effectively, little has changed. By omission, psychosocial aspects are taught to be fluff, stuff that is nice to know – if you have the time.

So, I ask: Is it possible that a format based on the assumption of acute illness is failing us in the era of chronic disease?

 

 

What Could We Have Done Better….Part 2

Life’s Hard-learned Lessons

“If people bring so much courage to this world the world has to kill them to break them, so of course it kills them. The world breaks every one and afterward many are strong at the broken places. But those that will not break it kills. It kills the very good and the very gentle and the very brave impartially. If you are none of these you can be sure it will kill you too but there will be no special hurry.”

-Ernest Hemingway, A Farewell to Arms

After reading my first post, if you did,  you probably felt the anger, and there is anger.  However, anger is not the only thing left.  I have found a lot of a lot of comfort in literature and art over the last year.  Art has the ability to make the very sad also very beautiful, which is at times  is all we have to hang onto as we wander through the wilderness of grief – the beauty of life.

And in those wanderings, you learn a great deal.  You learn about yourself, about your spouse, your family, your friends, and the world at large.  If approached in a certain way, it can be a great gift.  Do I wish my daughter could have lived independently?  Absolutely.  Do I wish I could go back to being the person I was before?  No.

I am so much more rich and human than I was before.  Yet, I have been broken by a double grief.  The grief for a life with a child that is not here, but also the grief for a medicine that supports and heals – both patients and their community of healers.  I am comminuted, displaced.

By Bill Rhodes from Asheville – mid-shaft humeral compound comminuted fx lat, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=5784840

My anger is actually not all that personal.  I certainly would not count my former partners as friends, or even colleagues.  I have come to understand how deeply medical training unmakes and then remakes a person.  After 4 years of premed, 4 years of medical school, and 3-5 of residency with possible fellowships thereafter, you have been destroyed and remade in the image of Medicine.

It is often not for the best.  I do not think my former partners or administration were particularly good people, nor do I think they were particularly bad people.  I think they were products of the system, which it takes amazing strength and courage to fight day in and day out.  The system never rests, doesn’t take breaks.  It has no humanity.  Who is strong enough to confront that?

And there is the problem, if I just thought that I fell in with a bad group of people, then I could just find another practice and feel like everything would be okay.  However, increasingly, I think that what I experienced is the natural outgrowth of our current Culture of Medicine.  Over at the Happy MD he refers to it, in part, as the “Lone Ranger on a Gerbil Wheel Syndrome.” How can you save anyone else if you are drowning yourself?

Now, I find myself a nomad doctor on the High Plains, too wounded to try and commit to another organization, community, or practice.  Seeing patients I can do, but I have to use shiftwork to protect myself.  I am too vulnerable, I had grown to love primary care and find purpose in healing.  I cannot take another heartbreak right now.  With time, I may become strong again at the broken places, but the callous around the bone is fresh.

I am still “non-weightbearing.”