A Shift as Death’s Attendant

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

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

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

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

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

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

“Still in asystole.”

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

On the Banks of the Styx

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“I am her son, what is going on?”

“What have they told you so far?”

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

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

He sighed audibly in the phone.

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

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

Silence.

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

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

“About 25 minutes.”

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

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

It is such violent dance, these days.

Time of Death, 18:00

12 minutes later, I made a phone call.

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

“Thank you for everything you’ve done…”

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

The Strange Calm

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

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

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

But, whose sensitivities are we really protecting?

Breath, Light Awareness

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

Luxuries, I suppose.

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

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

Click…Click….Click

“Patient arrived by EMS transport in extremis….”

Walking the Ghost Road

Working as a doctor in small towns on the High Plains, I have learned to do without a lot of luxuries. Those practicing in larger centers would consider many of these things necessities, such as being able to consult someone to the bedside, ever.

I do, however, have one luxury that is exceedingly rare in world of Modern Medicine, time to reflect. As I often only see 5-10 patients in a 24 hour period, I sometimes have a good deal of this.

Moreover, now that I have an infant at home, the time I have to reflect while at work is even more precious. I have yet to find a way to sell my 2 month old daughter on the value of quiet contemplation.

Since high school, I have tended to reflect while walking. When I screwed up a test, or embarrassed myself at school, that evening I would go on a long walk, sometimes for hours. I would meditate to the slow movement of my small town past me.

I still do this. Today, I took a walk on the slight hill above the hospital. A “wellness path” winds its way through the buffalo grass, prickly pear, and yucca. I walked the path in laps, waiting to be called in.

Those Who Came Before

Halfway through a lap, I came to the single grave that marks the halfway point. It is a modest affair. A small white headstone with only three letters marks the spot.

The earth over the grave is covered in the same high plains vegetation as the nearby pastures. Prickly pear and rabbit brush grow up around the headstone. Eventually, someone erected a very sturdy pipe fencing around the grave, likely to keep cattle from rubbing on the grave marker.

Perhaps most interesting, this lonely, solitary grave belongs a fellow physician. In the late 19th century, a wayward doctor had settled in this water stop town on the railroad. The townsfolk laid him to rest on a slight hill that overlooks the shallow, cottonwood-dotted valley of a seasonal stream.

I lean against the iron fence and stare up at the night sky. It is a wonderfully clear and dark night. I savor the lack of light pollution and the horizon to horizon views. Scanning the southern sky I see the milky way.

The Ghost Road

In Lakota cosmology, the milky way is known as the Ghost Road. It is the path all spirits must walk on their way from this world to the next. I let myself get lost in the imagery of walking through the galaxy as a spirit.

As I imagine my spirit side-stepping stars, I remember my fellow physician next to me. He walked that road over 100 years ago as a young man. Less than forty, it looks like. It is near impossible to imagine the life and profession of a true frontier doctor.

Nonetheless, profession and location bind us together. We have both doctored and cared for people in this little town. Even if the march of time makes it impossible for us to know each other as people, we are related.

This is also a Lakota idea – Mitakuye Oyasin – We Are All Related.

I reread the plaque explaining this grave.

A Life in a Paragraph

The good doctor had arrived in 1880. Two years later smallpox erupted in town (could he have imagined an era when doctors would have never seen a case of smallpox?). An old cow puncher came down with disease, and the good doctor cared for him.

The old cow puncher recovered, but the good doctor contracted smallpox. He eventually succumbed to the disease and was laid to rest on the same lonely windswept piece of prairie where I talk my contemplative walks.

“A good doctor…and a good man.” The plaque states.

Does the brief story on the plaque have meaning for me as a physician?

This physician died in the service of others, and I complain about not feeling fulfilled by modern medicine. In his calling, he sacrificed everything. Noble? Maybe, but also a complicated legacy.

From the plaque I also learn that he left behind a wife, who had accompanied him from the East. It does not say what happened to her out on the alien High Plains, alone, in grief. He also left behind an isolated, frontier town without a doctor.

How many went undoctored in his absence? I will never know.

Doctors Get Sick, Too

The irony of his death from the disease he was treating is not lost on me. Physicians are part of the societies they inhabit. Inextricably linked. In medical school, I often heard vague citations that physicians have higher rates of heart disease than other professions.

Most of these statistics came from before we started to turn the tide on heart disease. This was before cholesterol drugs and anti-hypertensives were mainstream, but when smoking still was.

Now, on the internet, I read about the burden of stress, anxiety, and depression doctors bear. It is no surprise, mental illness and its complications (i.e. addiction) seem to be an epidemic sweeping our country.

Why should doctors be immune? Especially, if we spend hours and hours caring for people with these diseases, is it no surprise some of it might rub off on us? You cannot vaccinate yourself against despair, loneliness, and disconnectedness.

Yet, We Are All Related.

I step away from the fence, feeling indebted to this long departed colleague of mine. Many, many things have changed in Medicine. Nonetheless, some things seem not to change.

Being a doctor is a hard job. It demands a lot. More than any one person can reasonably be expected to give. Yet, we do give, repeatedly and sometimes to excess.

The good doctor on that hill on the High Plains gave all he had to Medicine. It was sacrifice, yes, but I don’t want to glorify it. I will not say Dulce et Decorum Est Pro Medicina Mori.

Nonetheless, for a moment, I feel connected to a different kind of Medicine.

Not the Medicine of RVUs and production targets and treatment algorithms, but a deeper calling to serve humanity.

I’d like to think I can be doctor without sacrificing everything. But it is a delicate balance, and more often than not and I am too far one way or the other.

My eyes trace the line from his headstone to the Ghost Road in the southern sky.

At least, I think, I am not alone on this road.

Rugged Individualism Dies a Slow Death on the High Plains

If the High Plains had an official philosophy, it would be Rugged Individualism. The Rugged Individualist bends nature to his will under his own might and survives despite all odds on his own ingenuity and hard work. He is the mythic paragon of High Plains citizenry.

Of course, the myth holds up poorly when we take a closer look. The High Plains are very lightly populated. As such, individuals are even more dependent on community and society at large than in many cities.

Sometimes those bonds are strikingly personal. I walk into gas stations on the High Plains regularly. Without fail, a collection jar for some young person injured in a farming accident or suffering from some unexpected disease greets me when I enter.

More commonly though, those dependencies are complex networks of support. They are often not apparent on the surface.

Indeed, the entire economy of the High Plains is largely based in government support (save for grassfed ranching). Subsidies for corn, wheat, and cotton support the agricultural economy. The states and federal government pay for the education sectors. Medicare and Medicaid pays for the care of the ill and elderly, who make up a disproportionately larger share of rural populations.

Medicare and Medicaid are the lifeblood of the few hospitals who manage to eek out an existence on the High Plains. The numbers of the privately insured are too low to fatten their bottom lines. Indeed, a state’s decision not to expand medicaid has been linked to increased rural hospital closures.

Nonetheless, the Myth Lives On…

Despite the evidence supporting the dependency that rural areas have on the government and community institutions, the myth of the Rugged Individualist lives on.

Some of this is understandable. Many people on the High Plains have grown accustomed to handling challenges on their own. In the day to day of their lives, their lived experience is one of having to be very independent and resourceful.

Moreover, people place a huge value on “straight talk” on the High Plains. The residents of the High Plains are quick to dismiss any delving into complexities and grey areas as a form of obfuscation. As such, discussions on how economically dependent the High Plains are on the federal government are easily shut down.

But Why the Rugged Individualist?

The Rugged Individualist is part of the Defining Myth of the High Plains. Be they sodbusters or cowboys, those myths give a sense of place and identity to the High Plains.

Myths are powerful things. To destroy a Defining Myth is to philosophically destroy a person. He/She will resist it all costs.

Communities and individuals cling tighter and tighter to such Myths when they sense risks to their survival. The popularity of Brexit among much of declining working class Britain may be an attempt to reassert the Defining Myths of Britishness.

Similarly, the High Plains are on a century’s long economic and demographic decline. Small towns throughout the High Plains are teetering on the edge of viability. Every ten years we see how they are slowly hemorrhaging population. As such, their Myths have increased in importance overtime.

People and communities need to take pride in something. If they cannot take pride in their economic vitality, robust institutions, and entrepreneurial populace, people will seek solace in their Defining Myths. In this case, it is the Myth of Rugged Individualism.

This even seeps into the culture of healthcare in the region.

Treating the Chronically Ill Rugged Individualist

Contending with the myths of Rugged Individualism is one of the more exasperating parts of my job.

I see many people with multiple chronic diseases requiring huge amounts of medical intervention. Despite this, they continue to live 20 minutes from town on a farm/ranch or even just an acreage.

They have little to no family support. This is usually because the kids all left for the city and jobs. Sometimes, it is just clearly because the individual is such a goddamn pain in the ass.

Acutely, they are often suffering from COPD/CHF exacerbation, lumbar fractures, chronic wound infections, chronic debilitation from limited activity, or any other number of chronic complaints. To any reasonable discerning observer, the root cause is chronic deterioration of their health without social support.

Nonetheless, they cling to their need to live “independently.” Somehow, routine hospital stays, home health, huge expenditures of time and assistance on the part of family do not constitute “dependence.”

The Rugged Individualist often confuses stubbornness for strength.

An Encounter With a Chronically Ill Rugged Individualist

I am sitting in the clinic office finishing a note and the phone rings. A nurse from the hospital calls and asks if I can take a look a patient. The patient is here for some outpatient wound care.

The nurse goes on, “We had her in swing bed last week for rehab. She has been home for less than a week. I am worried that she might have cellulitis under her pannus.”

I walk into the room. The patient is laying diagonally across the hospital bed, feet dangling off the edge. The position is awkward and unnatural. I introduce myself.

“I am the On-Call doctor, do mind if I look at your wound?”

She barely acknowledges my presence “Go ahead.”

The nurse and I retract her pannus. Underneath is the characteristic beet red color with cheesy accents of a massive yeast infection in the folds of skin.

“Ma’am, you have a yeast infection. Are you able to keep the area dry and clean at home?”

“No, I can’t reach it and no one’s ’round to help.”

Afterwards, I learn the two home health agencies which service the county refuse to work with her.

“Yeast lives in warm, moist environments, like in between your skin here. All the medicine in the world won’t keep this from happening if you can’t keep it dry and clean.” I begin to explain.

“But I can’t reach it and I ain’t got no help.”

I continue. “So, you can’t take care of it yourself at home and you have no help. The only other option is living in a facility where there is help. Like a nursing home.”

She bristles as expected, “I ain’t going into no damn nursing home.”

“Well, then this is going to keep happening.”

She nods her head in reluctant acknowledgement and says nothing more.

An Institution Funded through Enabling

A good number of the acute inpatient admissions I do are effectively the result of chronic ailments getting so far out of control so as to justify admitting someone to the hospital. Basically, the hospitals stay afloat through enabling the untenable living situations of the chronically-ill.

This is largely achieved through federal tax dollars. Those hospitals prevent people from dying alone in their homes or being dispositioned to a nursing home in a larger town after a hospitalization.

I recently related a story about intubating a woman with end-stage COPD. As far as I know, this was her 3rd-4th time in a year. She had only been home 2-3 weeks after a long hospital and rehab stay. In the nursing home, she had done well and improved with simple, attentive care.

She spent 10 days intubated in the ICU, at which point they placed a tracheostomy tube sent her to a facility which specialized in long term ventilated patients. It only took a few weeks at home without attentive care for this to happen.

After years of hospital admissions, intubations, and nearly dying multiple times, she is now ventilator dependent. This will likely be for the rest of her life. I don’t know if her staying in the nursing home would have kept her off a ventilator, but I do know that attempting to live “independently” hastened the course.

I have watched her story play out over and over again. In residency we referred to it as “tuning ’em up.” We’d admit someone, diurese them, and send them back to the same dysfunctional environment which allowed them to get so out of balance in the first place.

The hospital bills Medicare, we all collect a paycheck, and we do it all over again.

The Costs of Healthcare Individualism

Americans believe in the rights and importance of the individual above all else. Similarly, we place patient autonomy atop the ethical totem pole in US healthcare, even if it leads to harm.

The incentives in our medical system have created a structure which ignores the interconnectedness of the patient to their broader world. We spend little on the social determinants of health even though they are far more predictive of health outcomes than clinical medicine.

The importance we place on the individual ignores the reality of human existence. Connection and dependency define humanity. Humans are inherently social animals. We need each other and our surroundings affect us immeasurably.

In attempting to treat the chronically-ill as rugged individuals, we deny their connectedness. Ignoring those bonds, especially with the chronically ill, continues to lead to enormous inefficiencies and harm within our healthcare system.

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.