Back to Work

I haven’t posted in a while. Not surprisingly, I have been somewhat occupied. Our new baby requires plenty of work, time, and love. Blogging hasn’t seemed all the important in comparison.

However, I am back on the High Lonesome, which brings with it periods of down time. This time is ripe for blogging.

Being back in the doctor’s role is an interesting transition from new father. Especially, after all the struggle over the last year and a half.

A Baby Brings Perspective

In some ways, I have a newfound acceptance of the failings of medical culture. All the pettiness, greed, and self-importance of many of the actors in a hospital are easier to tolerate, because the reason I show up is so much more important now.

Sometimes the work is its own reward. The times when I actually connect with a patient can sustain me – for a time. The rare critically ill patient who my team triages, treats, and transfers effectively can boost morale and help add meaning to the work.

Nonetheless, the reality is, most of any profession or job is mundane. Having a reason to go to work outside of paying off of my loans and funding my own diversions adds meaning to the mundane – especially when you are paid by the hour.

Knowing that my daughter is home and depends on me adds a certain nobility to the simple paycheck. It helps put a little shine back on the tarnished image medicine has for me.

Yet, on the first day of returning to work at one of my frequent work locations, I end up in my first meeting in over a year. Somehow, we are now having meetings….as locums.

I was scheduled to work and the ED wasn’t busy, so it didn’t turn out to be a big deal.

Of course, the main action item of this meeting was how to improve our billing and reimbursement. After only 3 years in practice, I am almost positive no other kind of meeting exists in healthcare.

This one specifically focused on improving critical care and procedure billing.

Good to be Back!

Other than this inauspicious start, the first day of the shift went fairly well. Going back to a familiar site was a good call for a first shift back. Weirdly, I seemed to actually enjoy being in the hospital.

The hospital had changed the way the local docs rounded in the hospital. This had actually improved communication and the nurses were asking me less questions about patients whom I didn’t know.

Finally, a change whose goal was improving patient care that delivered some results.

The first two patient’s were turfs from clinic for a DVT rule out and a CHF exacerbation. I quickly and efficiently ruled out the DVT. The CHF patient was known to me so the work up and admission to the hospital ended up being fairly straightforward.

Having wrapped up this work, I noticed a lull had set in. I went to the doctor’s quarters in a nearby house to rest and put some space between me and the hospital (it always seems to make the shifts go quicker). I felt good.

Watching some Netflix and making dinner, I waited to be called in. Around 11 pm, I got a call. An ambulance was out for someone who was found down and unresponsive.

An Actual Emergency

I find this chief complaint to be one of the most varied in actual cause. Benzodiazepine overdose, DKA, patient already deceased, sepsis, vasovagal episode, seizure – it could be practically anything.

In small low acuity EDs it tends towards the more mundane. Nonetheless, I headed back the ED and arrived right as the patient was being wheeled into the ED bay.

I recognize her immediately. She is a chronic respiratory disaster.

At 57, She already has end-stage COPD with multiple intubations in the last 12 months. This is, of course, coupled with right-sided heart failure. Shockingly, her kidneys are okay.

Her family has been told multiple times she may never come off the ventilator and she always has – so they now think she always will.

I know her to be angrily, vehemently, and obstinately FULL CODE, despite her terrible chronic disease and inability to care for herself at home.

She has had repeated blood transfusions for anemia which is of unknown source because her respiratory status is too tenuous for endoscopy. Not surprisingly – she also has terrible veins and recently finished a prolonged course of IV antibiotics through a PICC line (which I noticed sadly had already been removed).

“Oh, Shit,” I think to myself.

I look at her on the gurney. She is on a nonrebreathing oxygen mask. Oxygen is actually reading in the high 90s – remarkably good for her. But you can hear her audibly wheezing. Her chest heaves almost off the bed as she breathes in, and then her breath just slowly leaks out.

Her GCS is 3. Yelling, sternal rubs, nail bed pressure – nothing.

Getting to Work

We all get to work. An intraosseus line is placed in one leg – she gives no indication of being aware of a needle being drilled into her tibia. The nurses draw blood and send it to lab.

We give her narcan – she is on a large number of narcotic pain medications. Again no change.

I have the team set up for her intubation as her oxygen levels are starting to drop. Positioning myself at the head of the bed the intubation kit lays ready. I tell the nurse to push the anesthetic, then the anxiolytic, and finally the paralytic. She stops breathing.

Opening her mouth, I slide the laryngoscope into her mouth, visualize the cords, and slide a number eight endotracheal tube into her trachea.

We secure the tube, verify correct position, and begin to breath for her. All in all, it goes pretty well. The chest X-ray shows pulmonary edema, possible infiltrate, ET tube in good position.

Her labs come back, possible sepsis, blood gas shows a PCO2 of 124 prior to intubation. Methamphetamines in her urine. We start sepsis and influenza anti-infectives, give steroids, and get her ready to transport to ICU.

All in all, from arrival to transfer, we do this all in less than 3 hours. Not bad for a family doc in a two-bed emergency department 100 miles from the closest trauma center. Also, it is snowing, so the helicopters won’t fly – she has to go by ground, of course.

The Thrill of Being Present

As she leaves in the ambulance. I am feeling pretty good, alive. We just saved a life – for now. I just spent three hours completely engrossed in something pretty amazing – working as a team with people who gave a shit on something important. It can be intoxicating in small doses.

I like critical care. I like obstetrics (though I don’t deliver babies non-emergently anymore). What I love is the focus on the task at hand. The power of a small group of people fully engrossed in what is happening in that very instant can be amazing.

Both critical care and obstetrics demand this kind of focus. We should all strive for that kind of focus in all aspects of our practice. Sadly, this is difficult given the seemingly coordinated effort to destroy it going on around us.

The High Fades

After a rest and a drink a water, I walk back to get some sleep – it is 2:30 AM after-all. On the walk, I can’t help but feel a tension between the excitement of caring for a critical patient and the ethics of how we spend healthcare dollars in this country.

How many intubations is too many for one person? Is it ethical to repeatedly intubate and, God forbid, actually code someone who lives on death’s doorstep every day?

Does one person have a right to unlimited medical expenditures to prolong their life? How many childhood vaccinations could that cover? How many addiction treatments, or early parenthood interventions could we pay for?

The methamphetamine in her urine and her 3 different narcotic prescriptions are evidence of a life of great suffering. That suffering predated her current illness. Indeed, the smoking and drug use which caused it were likely attempts to numb that suffering for decades.

Is it ethical because these are the patient’s stated wishes? Or are we just hiding behind a weak patient autonomy argument so we don’t have to wrestle the suffering we witness – and prolong.

The things we do to save a life, needles drilled through bone, tubes into bladders and lungs. It would be torture in any other situation.

I feel guilty about how excited I was afterwards – even though I saved her life. I also kind of feel guilty about that…

When is it too much? When is continuing to torture someone to keep them alive, and suffering, unethical – even if they demand you do it?

Are these even questions we can ask in American Healthcare?

Recognition

A week later I get an email from our new ED medical director:

“Doctor HP,

Great job with the care of patient #1234567 in the ED last week. Your documentation of the intubation and critical care time was excellent!

Sincerely,

Your Medical Director”

I sit back and sigh, good to back working again….

Are Population Health Initiatives Doomed to Fail?

In the world of medicine, population health is a hot topic. This is especially true in primary care. Our longitudinal relationships with people over years (at least in theory) and interest in prevention make us a logical starting point.

However, as I have said before, our healthcare system encourages increasing specialization, fragmenting of care, prioritizing acute problems over root causes, and increasingly using customer satisfaction as a metric.

As a result, it is particularly poorly constructed to address population health.

Medicine

Definition: The science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease.

The science and art of medicine does not trace its roots back to basic scientific inquiry, but rather to the universal role in human societies of the Healer. We have always been Healers first, scientists second.

Medicine incorporated science to improve our healing abilities. We did not come out of the lab and decide to start healing because our science gave us that ability.

Healing has always been an individualized art.

The first step in the treating a patient is to ask personalized, individual questions. This is quickly followed by the laying of hands. It is a deeply individual and personal ritual.

Physicians are not public health workers (though some do get involved). No one trained us to treat whole communities or groups of patients with a certain diagnosis or condition. We treat individuals.

This is an inherently different task than improving the health of communities.

Population Health

Definition: The health outcomes of a group of individuals, including the distribution of such outcomes within the group.

Intensive, individualized therapies are unlikely to be effective at addressing population-wide problems. These problems require population-wide treatments. Even large physician/hospital conglomerates do not possess such a level of power and influence.

For instance, the evidence the USPSTF uses to recommend for obesity screening is that intensive (12-26 sessions per year) behavioral interventions resulted in a 6% average weight loss in studies.

This is a hugely expensive intervention on a single individual. Does it work, yes. It is an efficient use of funds? Probably not.

On the other hand, emerging data shows us soda taxes do result in statistically significant BMI reductions across a population. Not a clinically impressive amount, but still significant on a population level. This is most noticeable in poorer subgroups – people most likely to suffer serious complications of obesity related diseases.

This was done without the expenditure of public or insurance funds, or the involvement of physicians and expensive healthcare infrastructure.

Nobody’s Business

 The truth is, no one in the public or private sectors currently has responsibility for overall health improvement.

-David A, Kindig MD, Phd

Policy makers are looking at our healthcare system, seeing its huge expense with relatively poor outcomes, and want us to do better. In steps the idea of population health. In theory, a worthy goal.

However, no institution or sector currently has responsibility for this goal. Since we spend so much money on healthcare, that industry seemed like a good place to start.

Sadly, it seems policy wonks are trying to avoid the politically difficult conversation of funding of our public health infrastructure.

Instead of using public health – a developed field with solid data and methodologies – they seem to being trying to use a highly specialized and individualized tool to do a brute force job.

It is like using a coping saw to clear cut a forest. I guess you could do it, but it isn’t going to work well.

Responsibility without Power

I see this as a larger and larger shift in healthcare where the Corporatists are trying to burden clinicians with as much responsibility as possible while controlling levers of power.

The inherent task of designing the assembly line is to divorce the cognitive aspects of a task from its execution. (i.e. Clinical algorithms designed to help clinicians now being used as metrics) Thus, the managers maintain the power, prestige, and wealth of the task without the responsibility.

For instance, clinical care accounts for only 10% of a patient’s total health. Thus, we have little to no influence over the vast majority of what determines a person’s health.

Yet, population health initiatives want to hold clinicians accountable for it.

Moreover, populations are not static within even the largest health systems in this country. People change insurers, they move, they doctor shop. To influence the rest of the pie, the population must have a long term relationship with the institution/clinician.

That is not American healthcare.

Good Money After Bad

But perhaps most importantly, why would we give the same organizations which have spent astronomically large sums of money creating an ineffective system more responsibility to improve our health?

They have more than proven they are not up to the task.

I am in favor of improving population health. The attempt to redesign an already bloated and dysfunctional system to do a task for which it is not prepared simply seems like a waste of time and resources to me.

We need a robust healthcare infrastructure to address the needs of the ill in our society. We also need a robust population health infrastructure focused on efficiently improving the our health so we require less of the expensive healthcare infrastructure.

These are two totally different tasks.

An attempt to blend these goals into one endeavor is classic “straddling strategy.” Rather than choose one goal and pursue it, we are trying to to do two inherently conflicting tasks at once.

The end result will be failing at both.

The Freedom Fallacy

Freedom so often means that one isn’t needed anywhere. Here you are an individual, you have a background of your own, you would be missed. But off there in the cities there are thousands of rolling stones like me. We are all alike; we have no ties, we know nobody, we own nothing. When one of us dies, they scarcely know where to bury him… We have no house, no place, no people of our own. We live in the streets, in the parks, in the theatres. We sit in restaurants and concert halls and look about at the hundreds of our own kind and shudder.

– Willa Cather, My Antonia.

In all the talk of financial freedom/independence, we often forget to address the underlying fallacy in that assertion. Freedom or independence is impossible and possibly not even desirable.

We can be independent of many things. We can be independent of debt, wage work, even the power grid. However, that independence always comes with a cost (except maybe debt).

If we save enough money to stop working, we become dependent on the market, the value of the dollar, etc. Living off the power grid makes us dependent on sunshine, a gasoline generator, or our own ability to cut, split, and stack firewood for heat.

Indeed, living off the grid is satisfying not because of the freedom from industrial society. Rather, the connection to the natural world that it provides satisfies the soul.

Besides, connections and interdependency are essential traits of humanity. We need community, belonging, and purpose to live rich rewarding lives. Independence and freedom should not be the goals.

Rather, the things of which we desire to be free are often creating harmful relationships. We should not spurn connection, but those things we are connected to which are harming us.

The Value of Work

Far and away the best prize that life has to offer is the chance to work hard at work worth doing. – Theodore Roosevelt

I have started reading Shop Class as Soulcraft, by Matthew Crawford. I am not very far in, but it seem our desire to be free stems from our devaluation of work. Our society has been chronically and inexorably devaluing work since Henry Ford.

As work itself is devalued, the Corporatists are able to alter it in ways that make it less and less rewarding for individuals. They buy our silence with increased remuneration so we can pay for things we don’t value.

We cannot value a thing if we don’t respect the work inherent in its making.

The reward of operating a drill press repeatedly in the same way day in and day out is far less than building individual pieces of furniture which can you can admire in completed form and be proud of.

In my own craft of doctoring, we see the finished product – healing and the healing relationship – increasingly being pulled from our grasps as physicians. The system is cubiclizing our craft.

Our patients, so accustomed to this reality in every other part of their lives they do not seem to care all that much. As long as they get their product, a Z-pack for a viral cold, narcotics and benzodiazepines for the pain of existence, unnecessary orthopedic procedures, they are satisfied customers.

The sad thing is, I could make more money doing 30-40 of those visits in a day as a medical automaton (and I have witnessed plenty of physicians who are doing so) than I could truly trying to heal.

Freedom vs. Fulfillment

While I think financial independence is worthwhile, by focusing on the end-goal we often forget to do the hard work of examining why we desire them in the first place.

This desire stems from a deep satisfaction with our work. As a people, we seem to inherently no longer find satisfaction and value in our work. Now, some might argue this is just Millennials being lazy.

However, isn’t it just as possible that something in the world of work has inherently changed over the last 50 years? That work is literally not what it once was.

Two trends are crossing right now. The trend of devaluation of work has continued unabated since Henry Ford and is reaching parts of our economy that were previously immune. This trend is intersecting with an increasing realization that money and consumerism lead to empty lives.

What is a person to do in an economy which requires us to do a thing we find repulsive to buy shit we don’t want? FIRE is one answer, but it simply postpones a reckoning.

We actually want fulfillment, and if we put the barrier of financial freedom between us and fulfillment, we increase the likelihood we will never get there.

Oh, So Many Red Herrings

Why do so many bloggers who have reached financial independence keep blogging? Because it is a path to connection and creative work.

We can obtain both of those things before FIRE. We do not have to postpone a meaningful life until we have “Fuck You Money.”

What pushes people who have enough money to stop? Not the number in the bank, but the dissatisfaction the work provides.

So, like most things in life the problem isn’t money or lack there of, it is more difficult. It is life, and it is much more difficult to rearrange one’s life and build meaningful work and relationships than to keep working for Fuck You Money.

The system is extremely adept at using money to keep us on the gerbil wheel. Even Fuck You Money can just be another carrot to keep the gerbil wheel cranking.

Accumulating money cannot be the answer to our existential woes, since it is clearly the cause.

Courage is not the Absence of Fear

The position of strength that John Goodman talks about in the Gambler does not require a a dollar amount. It requires courage, discipline, and clarity of purpose. We can learn and practice these things without a lifetime of money in the bank.

I said Fuck You (not literally, I do not recommend that) with over $300,000 in student loans and similar sized mortgage. What I had was Fuck Me Money, not Fuck You Money.

I still made the decision from a position of strength because I understood my marketability and cared more about the health of my family than anything else.

A year later, I have no mortgage (renting), and my student loans are over $100,000 smaller. We live in a 1500 sq ft house without air conditioning, the bumper of my work vehicle is kept on with duct tape and baling wire, and we are much happier.

Again, it had nothing to with a number and everything to do with living a life more true to ourselves.

So, go ahead, get that Fuck You Money, but don’t neglect connection and work worth doing in the process. If you do, you risk ending up all alone with no bills.

Hemingway and the Danger of Persona

I love reading Hemingway. I am unabashed about my love of his writing. Before everyone freaks out and starts listing all of the problematic aspects of Hemingway when viewed through a modern lens, I am well aware of all of the arguments against Hemingway.

Those arguments are part of the reason I love his writing. Simple, perfect people are useless when it comes to extracting lessons for life. No writer worth reading stays perfect through the centuries.

One of the best parts of reading Hemingway is the existence of a decent companion work which puts nearly every major piece of his work in perspective.

While I could write a book on these various topics, one that I have come to appreciate during my struggle to reclaim my humanity from medicine is the cautionary tale of the Hemingway Persona.

Personality vs Persona

When you read about Hemingway’s early personality the evidence largely points an idealistic, sensitive, and very motivated young artist. He wrote a lot about “manly” pursuits (fishing, hunting, etc) even his early days, but they are almost always a backdrop for extremely human and vulnerable emotional struggles.

Additionally, he drank too much, a common form of self-medication for the overly sensitive in this insensitive world. He was desperate for approval in his professional life and intimacy and adoration in his private life.

Big Two Hearted River illustrates this the best. I read those stories as a form of literary meditation repeatedly the winter after my daughter died. Indeed, I channeled a little of that story into one my posts.

In 1926, he published the The Sun Also Rises to critical acclaim. The literary persona of Jake Barnes (based off of himself), who fished the Basque Pyrenees and dodged bulls in Pamplona, captured the imagination of readers.

From that point on, Hemingway became that persona more and more in public. Over time, the work of putting on the mask invincible masculinity took its toll on Hemingway. It is worth noting that he projected that persona strongest in middle life, when men most acutely have to reckon with their inherent vulnerability.

Hemingway’s public narrative of invincible masculinity became increasingly untenable overtime. This, as well as a genetic predisposition to depression, alcoholism, and chronic pain from injuries in plane crashes led to increasingly deep depressive bouts.

In the end, he killed himself. After a life of building a persona which conflicted so deeply with his underlying personality, this is the only way Hemingway could have died. His public persona could only allow Hemingway to kill Hemingway. No other could have been up to the task.

Does the Doctor kill the Person?

Physicians, arguably more than most common professions, have a strong public image. Strong yet caring, never tiring, cocksure at times, in pursuit of the care of their patients.

Physician culture is very intolerance of aberrancy in this personality type. This is on display in a recent back and forth in the comments by a Douglas Hoy of one of M’s Posts over at Reflections of a Millennial Doctor.

A good portion of my medical school’s non-basic science or clinical education was spent indoctrinating us into the professional image of the physician. We all must wear professional masks. However, the pressure to fully become the mask of the physician is stronger than most.

While I think some people already are or become “the Doctor.” For the rest of us, those who were pretty satisfied with who we were before being physicians, this personality dissonance can be a deep struggle.

As Hemingway’s struggle with his persona show us, if the dissonance is too great, it can be fatal. In many of the stories of physician suicide, people reference this personality vs persona dissonance.

“She was always so happy.”

“Everyone loved him.”

“She was so successful.”

Dissolving the Narrative Dissolves the Self

For many, the risk of “being found out,” or having the persona destroyed is too great a risk. As I have said before, narratives are extremely powerful. We construct ourselves through narrative, if ours is at risk of dissolution, it can seem no different than death itself.

For instance, the country of Macedonia is changing its name to North Macedonia in order to join NATO. The narrative of Macedonia and Alexander the Great being Greek is so important to Greek identity that Greece has blocked Macedonia’s entrance into the organization. And people are still pissed off.

That is how strong narratives are. I am not victim blaming or minimizing the importance of clinical syndromes of Ddepression and anxiety.

However, part of the road to healing is identifying paths and actions we can take to work back towards health. One of those paths is the work of creating a physician persona that is concordant with our native personalities.

As usual, Hemingway says it best in his writing:

“The most painful thing is losing yourself in the process of loving someone too much, and forgetting that you are special too.”

― Ernest Hemingway, Men Without Women

In loving our idea of the doctor more than the person we are, we risk forgetting that we were already special, already worthy.

In the work of healing it is important to continue to be our authentic selves. I believe we will be most effective and keep ourselves and patients safer if we reclaim our humanity and leave our personas at the door.

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.

How the Corporatists Stole Quality

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

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

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

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

Clinicians Don’t Decide

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

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

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

I can be a team player.

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

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

Low-liability care is not quality care.

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

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

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

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

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

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

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

How did we get to this point?

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

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

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

Systemic problems rarely have individual solutions.

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

A Note of Gratitude to Medicine

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

A Tumultuous Year

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

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

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

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

The Shadow of a Loss

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

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

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

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

Giving Gratitude a Chance

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

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

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

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

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

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

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

Nonetheless, My Privilege is Great

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

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

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

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

Medicine giveth, and medicine taketh away.

Work isn’t Everything

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

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

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

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

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

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

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

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

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

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

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

― Kahlil Gibran

Uh Oh, I Want to Fix Things Again…

feeling the burn, again.

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

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

problem 1 – working too damn much

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

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

problem 2 – location monotony

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

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

Summary:  an emotionally draining patient population.

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

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

in the nomadic world – freedom is all

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

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

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

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

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

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

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

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

here’s the rub, i like fixing things

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

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

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

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

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

getting singed

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

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

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

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

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

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