Of Assembly Lines, Medicine, and Burnout

assembly line medicine: mourning the craftsmen

Historical fact: People stopped being people in 1913. That was the year Henry Ford put his cars on rollers and made his workers adopt the speed of the assembly line. At first, workers rebelled. They quit in droves, unable to accustom their bodies to the new pace of the age. – Jeffrey Eugenides, Middlesex

Prior to 1913, automobile manufacturing was a cottage craft industry.  Start to finish, a master mechanic with full knowledge of the entire process assembled the machine.  Henry Ford killed this industry with the assembly line and opened up automobile ownership to the world. 

Similarly, prior to the 1980s and 1990s, medicine was primarily a cottage industry.  Each physician a craftsman running his/her own shop from start to finish.  It was not all rosy: quality was unreliable, physician greed was a problem.

On the other hand, physicians had a much more interesting and varied work-life, being both business-owners, healers, and technicians.  That variation helped to sustain a long career.  If you avoided over-leveraging, altering your own business model was easier than changing your work structure as an employee of a larger organization.

the chains of credit

At first, Henry Ford could not keep workers in his new factories.  At one point, he had to hire 963 men to add 100 positions to his factory.  That is how intensely the human mind rebels against such simple, repetitive work.

How did he fix this problem?  He paid his workers $5 a day, double the prevailing laborer’s wage of the time.  Workers earning double what they had made before were more anxious to keep their jobs.  Another 20th century invention made them doubly anxious to stay employed: consumer debt.

Similarly, doctors incomes have jumped appreciably in the era of healthcare consolidation.  Moreover, they begin practice minted with six figures of debt.  We seem ready-made for the harness of the assembly line.

Anxiety and debt are powerful motivators.  Loss aversion is much more powerful than the desire for equivalent gain.  How do you harness that motivation to keep human beings at jobs they detest?  You allow them to have something in exchange for future work, in other words: debt.

Indebtedness could discipline workers, keeping them at routinized jobs in factories and offices, graying but in harness, meeting payments regularly. – Jackson Lear

I wonder what our physician workforce would like right now if we hadn’t had to accumulate $200k-300k in student loans first.  Would the assembly line still be moving at the same pace?  Would more physicians be buying private practices?

separating planning from execution

Currently, the healthcare giants are actively trying to replicate Henry Ford’s ruthless efficiency in healthcare.  This will likely result in more healthcare for all, as was Henry Ford’s goal.  The question really becomes, do we want more healthcare?  Is healthcare a commodity of which more is better?

The data suggests not.  Dartmouth Institute for Health Policy and Clinical Practice have estimated that 30 percent of all Medicare clinical care spending could be avoided without worsening health outcomes.  The basic positive that comes from the assembly line is an increased production.  What is the argument for applying that model to a system that is already overproducing?

Basically, the benefit is increased profit for large health systems.

While standardized processes and workflows are an important part of assembly line efficiency, the core philosophical underpinning of the assembly line is separating the planning of a task from the its execution.  The healthcare giants are attempting to separate the planning of providing healthcare from execution.

In my position as a staff primary care doctor, I frequently went to my supervising physician and CEO with concerns and plans to make things better. They were always polite, but I tended to leave feeling a doctor who said nothing and simply saw more patients was more desirable.

Individuals in positions of “planning” guard their role jealously, because if physicians independently planned and executed the task, it would obviate the need for the managers.  Of course, they want us just keep our noses to grindstone, as long as they are needed to “plan” they have jobs.

The less creativity and ingenuity providing healthcare requires, the less and less valuable physicians as a class become.  The machine strives to make us easily replaceable cogs in the wheel, it is designed to do so.  Increasingly then, our position feels less secure, our anxiety goes up, and we work harder at jobs we hate to pay bills and keep the fat checks rolling.

the disconnect

Even as the American Hospital-Pharmaceutical Complex pushes for more and more efficiency and standardization, the American medical training complex discordantly continues to train doctors for the role of the independent craftsman.

Is it any surprise then that we aren’t fitting into the assembly line well?  Medical school and residency overtrained us for the work the healthcare giants are asking of us.  Not shockingly, the average turnover in healthcare jobs in 2017 was 20.6%, up from 15.6% in 2010.  Will they be able to buy us back into system? Has debt burdened enough of us so heavily that the machine will continue to churn on?

I think that specialization and overspecialization play a role in burnout.  The assembly line demands as much specialization as possible.  In the process, the variety and type of tasks we perform decreases incrementally and consistently.

Eventually, we feel ourselves the carriage craftsmen, put out of work by Henry Ford, forced to toil in sickeningly simply tasks in the new factories. Of course, we  burn out and quit, if we have the option.  Too often though, we just keep at it, for the better paycheck.

lessons from butchers

Henry Ford got his idea for the assembly line from Chicago butchers.  This is something worth remembering as we continue racing down the current nationwide experiment of applying efficiency to American healthcare.

Now, we shuttle human bodies on gurneys from ER bed to MRI to operating room, extracting RVUs as they move.  Will the machine tame physicians, as it has tamed nearly all other industries?  Will we continue to gray in the harness?  Or will we demand something more from our sacred calling?

They had chains which they fastened about the leg of the nearest hog, and the other end of the chain they hooked into one of the rings upon the wheel. So, as the wheel turned, a hog was suddenly jerked off his feet and borne aloft….Neither squeals of hogs nor tears of visitors made any difference to [the men of the floor]; one by one they hooked up the hogs, and one by one with a swift stroke they slit their throats… [The Butchering Floor] was all so very businesslike that one watched it fascinated…And yet somehow [one] could not help thinking of the hogs; they were so innocent, they came so very trustingly; and they were so very human in their protests–and so perfectly within their rights!….but this slaughtering-machine ran on, visitors or no visitors. ― Upton Sinclair, The Jungle

Horseshoes and Hand Grenades

Reason for visit: cough – follow up from urgent care

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

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

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

History of present illness

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

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

Me:  Can you describe how winded you feel?

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

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

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

a closer look

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

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

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


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

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

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

admit to hospital

I went into the exam room.

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

B seemed neither relieved nor worried, “Okay.”

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

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

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

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

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

good catch, man!

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

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

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

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

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

when your best isn’t good enough

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

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


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

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

humility is a punch to the gut

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

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

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

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

reconciling polar opposites

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

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

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

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

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

the dead are never gone

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

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

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

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

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

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

Good Money after Bad

when is a relationship worth salvaging?

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

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

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

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

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

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

can you even have a relationship with a machine?

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

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

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

anatomy of a breakup

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

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


Inuidia – Envy

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

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

can our relationship be saved?

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

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

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

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

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

It’s the High Lonesome for a Reason

The plain gives man new and novel sensations of elation, of vastness, of romance, of awe, and often nauseating loneliness. – Walter Prescott Webb, The Great Plains (1931)

By Leaflet – Own work, CC BY-SA 3.0, Source: Wikimedia Commons 

Yet, America remains attached to the idea of Yeoman farmer and the rural bucolic existence.  It lays deeply burrowed in our collective mythology.  Many people who live in small town America are very proud of this association. Indeed, I have been to some places that seem to live this ideal every day.  They are very rare.

rural america is no spring chicken

Firstly, Rural America is much older than America as a whole (interestingly, the places where this is not true are largely in areas where refugees and immigrants are moving in to work in industrial agriculture – but we won’t touch that lightning rod for now).  Some of this age difference is due to youth moving to cities and larger towns for jobs.

However, I also increasingly hear narratives about people on fixed incomes – the disabled, the elderly, the rare retired military, government, or railroad worker who actually receives a pension moving to the small towns because of affordability.

This is especially noticeable in places not too far from larger towns/cities on the borders of the High Plains.  So, young people are leaving and older people moving in – a demographic double whammy.

what kind of person retires to high plains?

It takes a special kind of soul to thrive on the High Plains.  You have to love the sky and the wind and the sun.  You also have to be pretty self-reliant.  Self-Reliance is the central tenet of High Plains life, help is usually not close and may be unreachable.

Unfortunately, no amount of grit or curmudgeonliness will keep you healthy and independent forever, though it does seem to help.  I have seen dozens of people who retired to a rural area and bought a small acreage in their fifties or early sixties when they were still quite healthy.

This seems to last a good 5-10 years.  Property is a lot of work.  Roads may be plowed by the county after a snowstorm, but your driveway won’t be. A half-mile snowed-in driveway is a glacier to a wheelchair.  Moreover, 48-72 hours may pass before the county gets the road clear.

chronically ill in the middle of nowhere

One of my first patients in my real practice was Kathleen (obviously not her real name), an older woman who was supposedly in for a diabetes check up and establish care.  We sat down to go over her A1C and her medications.  A quick chart review revealed that she was undergoing treatment for Stage III-IV ovarian cancer, at 79.

Ovarian cancer that is this far along is not a curable disease.  It is what the patient will die from (if the treatment doesn’t kill them first).  Kathleen had already gone through surgery, chemotherapy, and radiation.  She was struggling to keep her medicines straight.

Her oncologist had told her this cancer was incurable.  Despite this, she still suffered through treatments thinking that a cure was possible.  We had hours of conversation about goals of care, she still wanted treatment.  It took me a while to understand this, seeing how much she was suffering.

caring for the seriously ill requires community

She lived on 2 acres on a gravel road, miles out of town.  They could be snowed in for days at a time.  She was too weak to cook for herself, she was losing weight.  Then I met her husband, he had significant dementia.

SHE was the caregiver in the relationship.   She felt she couldn’t leave her husband and his dementia made it impossible to reason with him. Children were in other states and not helpful.  Elder protective services were involved – but to no avail.

She was in and out of the hospital and the ED.  When you have no one to give you a ride and you are not doing well, the only option is the ambulance.  An ambulance can only take you to ED.   Discussions about nursing homes, hospice, assisted living went nowhere for over a year.

In the end, she had a chronic pneumothorax with an indwelling chest tube with a valve. She was constantly in pain and short of breath.  Finally, one of my partners transferred her to a hospice house an hour away, almost against her will.  She was simply too weak to fight.

This is an extreme example, but it is easy to imagine a bunch of hardheaded, tough people who are now on oxygen due to smoking, or with arthritis and limited mobility, or early dementia as yet unnoticed (no one has visited grandma in 6 months).

My experience doctoring over the last 2 years around rural America has left me feeling that the social isolation of rural America is literally killing people.

social isolation is a growing epidemic

The New York Times has written 2 articles on it within the last 2 years.  Additionally, an increasing amount of psychological and health publications are delving into the risks of social isolation, and it is more acute in rural areas.  These risks even include increased mortality.  This risk can be up to a 50% increase.

As a traveling doctor, I often feel powerless in the face of these realities.  I see people in the ED who are just destined to float back and forth between the hospital, nursing home, home (see hardheadedness above) and back until death or a permanent stay in the nursing home.  And I often just feel myself helping keep the assembly-line moving, unable to help renew the sinewy bonds of community.

Loneliness, thy other name, thy one true synonym, is prairie. – William A. Quayle, The Prairie and the Sea (1905)

On quiet evenings, when I walk around the edges of the little High Plains hamlets where I work, I stare up at that fantastic sky and think about my own isolation.  Watching the windmills turning wind to electricity on the ridgetops, I find the space to feel my loneliness.

By USFWS Mountain- Uploaded by Magnus Manske, Public Domain, https://commons.wikimedia.org/w/index.php?curid=21102582

The loneliest kind of loneliness is the that felt when surrounded by a sea of humanity.  The High Plains welcome those feelings of isolation.  The sky seems to open up and embrace the lonely. Some of my loneliness stems from the grief of losing my daughter, I know.  However, I also feel the professional isolation.

physicians are not immune

As I have said before, there are times where I am the only doctor in an area the size of Rhode Island.  I am almost never physically adjacent to others of my profession.

How does one stay connected to the community of healers without a home base? How do you discuss tough cases when you are the only one in the doctor’s lounge?

Increasingly, researchers are identifying feelings of isolation as playing a role in physician well-being and burnout.  I know that the isolation I felt in my acute grief and how my partners reacted was worse that than anything I feel now.  It is one thing to be lonely by physical distance, another when social and professional exclusion and competition isolate you.

I think that the rise of the physician blogging community is a reaction to these feelings of isolation that we have in our work space.  Physicians are supposed to be social people, to connect with people.  We need our community to thrive.

Self-reliance and rugged individualism appear to be contributing to significant suffering and premature death in rural America.  Am I too at risk?  I don’t know, but I am trying to do something about it, and hopefully it helps.


A Tale of Two Medicines

Bias in Medical Practice

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

tale one: rofecoxib

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

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

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

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

tale two: opiates

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

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

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

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

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

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

Rofecoxib and Opiates Kill People

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

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

to americans, addiction is a vice, not a disease

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

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

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

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

addiction is a terrible disease

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

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

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

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

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


An Introduction to Critical Access Hospital Doctoring Part 2

Doctoring on the High Lonesome

Hopefully, you read Part 1 of this series, or at least skimmed it (rural health policy isn’t for everyone) for some background. In this post, I will dig into why critical access doctoring is different.

rural family medicine vs critical access medicine

What is the difference between “critical access medicine” and “rural family medicine?”  Traditionally, rural family medicine practice was the “does it all” local doctor.  The doctor who saw patients in his/her own practice, admitted them to the hospital, took ED call, delivered babies, etc.

I currently don’t have a practice and am not a reliable presence in the communities in which I work.  I have no longitudinal relationship with patients. As such, I don’t really feel like I am doing “rural family medicine” in my current arrangement.

The bulk of what I do now is low acuity emergency medicine. Larger EDs label this  kind of care “Fastrack.”  However, I also have the occasional heart attack, stroke, sepsis, and trauma thrown in for sphincter training.  In certain locations, I see the occasional primary care patient or urgent care patient in clinic.  I also take care of low acuity acute inpatients.  On top of all that, there is the bag of worms known as “swing bed” in Critical Access Hospitals (CAH).

The biggest difference between critical access doctoring and being an urgent care doctor, hospitalist, primary care doctor, or emergency room doctor is that I am often juggling all of these responsibilities at once.  This demands a kind of mental flexibility and strategic thinking different from what I have experienced in more specialized settings.  Moreover, you are almost always doing something at the limits of your comfort zone.  You can call for advice (but rarely backup).  At times, I am the only doctor in an area the size of Rhode Island.

swing bed programs

Swing bed programs are designed to allow CAHs to “swing” some of their unused beds into post-acute care skilled nursing facility (SNF) beds.  CAHs most often use these for post-stroke, acute illness, or surgical rehabilitation services.  These services include: physical therapy, occupational therapy, speech therapy.  Occasionally, patients who require long term treatments such as IV antibiotics are swing bed patients.

The purpose of these programs is to allow CAHs another revenue stream to help them maintain their critical access mission.  The reimbursement for this is again “cost based.”  No hospital will be able to make a profit with swing bed services. However, they can get a lot of the costs covered that a hospital incurs from having nurses, techs, doctors on call or on the payroll just to have a basic level of service.

why can’t people just stay in the hospital?

Normally, swing bed patients are fairly easy to care for.  The acute care hospital (ACH) addressed their acute issues and it should be fairly simple from that point on.  In fact, the doctor only has to see them every 7 days, because they are not supposed to need acute care.  However, it is not rare for the transferring acute care hospital to present the situation in the rosiest light possible.

These patients are often chronically ill and debilitated and on government insurance such as Medicaid and Medicare.  These plans pay based on DRGs (diagnosis related groups). Meaning, for a given diagnosis, CMS pays an amount based on the average cost of providing care for the diagnosis.

So, once the ACH has dealt with their acute diagnoses, these patients are costing them money.  Especially if they are short of staffed-beds and having to turn away other acute care patients. They want them gone.

swing bed can be a solution

In the past, these patients might just be sent home or out onto the street by some of the more profit-hungry hospital systems.  If they came back, no worry, CMS paid them for the second hospitalization as well. Now, hospitals are getting penalized for 30-day readmissions.

Due to these new punishments, acute care hospitals want to get patients out of their hospital, but to somewhere from which they are unlikely to bounce-back –  SNFs(skilled nursing facilities), LTACs (long term acute care), LTCFs (nursing homes, assisted living, etc).  Basically, swing bed programs allow CAHs to function both as an acute care hospital and as a SNF.

This financial pressure on acute care hospitals means that sometimes the transferring hospital buffs the chart to make the patient seem less sick than they are.  It definitely happens where a patient arrived at the CAH, spent 1-2 nights, and quickly return to the ACH because of their illness acuity.

trials and tribulations of a swing bed patient

Specifically, I can think of a patient who had back surgery, was in the surgical hospital for 3 nights, then sent home.  She presented to our ED with worsening pain and inability to care for herself at home.  Due to her first hospitalization, she qualified for swing bed.  I admitted her to swing bed as there was no obvious acute diagnosis at the time.

Her pain worsened, she developed a fever, which in the end turned out to be secondary to a wound infection.  She returned to the acute care hospital for a washout and antibiotic treatment.  She was sent back to our facility for IV antibiotics and physical therapy.  3 days later, her wound was gushing with fluid again.  Back she went to the acute care hospital for another washout and treatment, after which the acute care hospital transferred her to an LTAC.

critical access doctoring

I spent a disproportionate amount of time on swing bed care because it is a type of medical care that really only exists in CAHs.  It is definitely NOT what I spent the majority of my time doing, but it is something that I had never encountered before working in a CAH.  It took me a while to wrap my head around it.  I have even hospitals that utilize swing beds often poorly understand it.  I hope that the discussion was useful for anyone who is trying to figure it out.

Finally, I hope this paints a basic picture of critical access medicine.  At its foundation, it is a commitment to meeting patients where they are, in a literal and geographic sense.  The challenge is that there is almost no routine and you are frequently reinventing the wheel.  This necessitates lower volumes as you have to think things over more carefully and can’t rely on muscle memory and reflex.  If you can handle those constraints, the benefits are more time with patients and more variety than almost any other practice environment.

An Introduction to Critical Access Hospital Doctoring – Part 1

Critical Access Hospitals (CAH)

I thought I would take some time to introduce the concept of the Critical Access Hospital and the kind of doctoring that is done in these facilities.  Likely, relatively few of you are familiar with them.

how do you define rural?

The relative obscurity of the CAH is natural, only about 19% of US population lives in rural areas.  Even fewer, about 3%, live in counties designated as “frontier.”  WTF does “frontier” mean, you ask?  I am glad you did, because it is one of my favorite little arcane facts about rural life.

In 1890, the US Census Bureau determined that the American Frontier had reached a population of about 6 people/square mile.  This, they decided, was a dense enough population to declare the frontier closed.  As noted above, 3% of the US population still lives in counties with a population density <6 people/square mile.  Thus is born the designation of frontier county, which is used in rural policy circles to denote a qualitative difference in the kind of rural life that exists in these places.

okay, but what is a cah?

CAH is a designation that can be earned from the Centers for Medicare and Medicaid Services(CMS). It is primarily based on distance from other services(generally 35 miles from the next closest hospital) and a few other a criteria, such as 25 or fewer beds, 24/7 emergency services, <96 hour average length of stay for acute care inpatients.

These facilities can range from having general and orthopedic surgery, internal medicine hospital, dedicated ED doctors and obstetricians to facilities that effectively have a clinic, and small 2 bed emergency department, and a few inpatient beds.  I tend to practice in the latter group.

Why would a facility want this designation?

Medicare cost-based reimbursement.  What does that mean?  For any inpatient treatments provided to medicare patients, medicare will reimburse critical access hospital 101% of the cost of providing those services.  This often includes costs associated with maintaining a hospital that often has empty beds.  It helps keep these low volume facilities, which are often located in poor areas, afloat so that they can maintain “critical access” to healthcare in rural areas.

why pay to keep these facilities open?

There is a moral argument that access to healthcare is important.  I tend to agree with that argument, but that isn’t really the reason why we continue support these facilities.  The real reason is that rural areas have a disproportionate say in national politics.

Let’s take the Senate for example.  There are currently 270,202 registered voters in Wyoming, that’s right, in the entire state.  In California, that number is 18,980,481, but California still only gets TWO senators. So, if I were a registered voter who voted in the last election and lived in WY, every time a senator voted in the Senate, 0.0000037 of that vote could be attributed to me.  A Californian on the other hand, can only be attributed 0.00000005 of his senator’s vote.  That is 74 times more representative power in the Senate for an active voter in Wyoming compared to California. The difference is less in the House, but still significant.

Let me be clear, I am not saying that I am opposed to these programs or that I oppose money being directed to rural areas for healthcare, education, or other social programs – my income currently depends on it, as a matter of fact.  I think these are interesting facts and realities about the macroeconomic forces at play in rural healthcare that are worth knowing.

But what about the doctoring?

In Part 2 of this series, I will discuss the actual doctoring that goes on in these facilities and what it is like to practice in these facilities.


Millennial Physicians Didn’t Start the Fire

millennial physicians

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

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

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

She wasn’t convinced that it was always necessary.


Do we have a millennial physician problem?

I’m not sure.


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

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

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

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

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

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

oh! the humanity!

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

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

the tribe vs the lone ranger

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

The H&P does not demand this kind of information:
  • Recently laid off
  • Homeless
  • Non-literate
  • Going through a divorce
  • Friend just got diagnosed with cancer
  • Sexually Abused as a child
  • Closest full-service grocery store is 5 miles from house requiring a 1.5 hour bus trip with 3 transfers
Source: https://nonprofitquarterly.org/2017/11/28/nonprofit-says-communities-not-doctors-must-lead-improve-health-outcomes/

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


the h&P assumes a certain level of baseline health

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

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

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

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

THis tendency has been recognized before

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

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

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



Tom Petty was wrong, it’s not the waiting, it’s the “being with” that’s the hardest part.

Dr. Sanders had been dying a long time. Bald and infected, quiet and cachectic, he was getting his life in order. We were friends. He was dying with a calm strength, as if his dying were part of his life. I was  beginning to love him. I began to avoid going into his room. 

"I understand," he said, "it's the hardest thing we ever do, to be a doctor for the dying." 

Talking about medicine, I told him with bitterness about my growing cynicism about what I could do, and he said, "No, we don't cure. I never bought that either. I went through the same cynicism— all that training, and then this helplessness. And yet, in spite of all our doubt, we can give something. Not cure, no. What sustains us is when we find a way to be compassionate, to love. And the most loving thing we do is to be with a patient, like you are being with me."

-Samuel Shem, House of God
high plains doctoring

The other day I was out on the High Plains, doctoring.  In this particular location, the ED isn’t very busy, so I also cover a walk-in clinic at the same time.  Usually, this is standard urgent care type stuff.: kids with fevers, ear infections, sinus infections, headaches, bronchitis.  Occasionally, I get a follow up from some other practitioner and I have to piece together what was going on, what the plan was, and what is going on now.

I looked at the schedule: follow up rash – not getting better.

This particular patient received one opiate medication as a refill accidentally instead of her usual one and she had developed hives from it (a known personal reaction, apparently).  She completed course of montelukast, prednisone, and H2 blocker about 10 days ago and got her opiates straightened out.  Initially, she improved, but once she finished the prednisone, she continued to get daily itchy, red, urticarial (hive) rash. It was temporary with no discernable trigger. She did not have a rash in the visit.

Normally, this would be pretty robust hive regimen and, for a single exposure, should have taken care of it.  She had no known other exposures or new foods/soaps etc.  So, I asked her about stress.  I have already seen a few cases of stress urticaria in my short career.  People are generally much more willing to talk about stress in their lives than their “mental health” or “anxiety.”

Critical Access Hospital Medicine Truth #1: You are more likely to find artisanal kimchi on the High Plains than adequate mental health resources.

And the flood burst forth!  As it happens, she was nearing the 1 year anniversary of the murder of her grandson with whom she was very close and whom she raised as her own child.  On top of that, news was slowly coming to her about when the trial would start and, like all of these bureaucratic occurrences, it was start-stop.

Had she seen or talked to anyone about this over the last year.?


Are interested in counseling?

We discussed places for counseling – there is only one mental health service in this area – an hour away – and they have a bad reputation in this community, so she wasn’t interested.

We discussed a pastor/clergyman, this was a possibility.  Her grandson had been close with a local pastor, I encouraged her to talk to him about her grandson.

Grief is not a disease, it should not be anesthetized away.

And then she began to talk to me about her grandson, she told me stories, what he was like, how he cut his hair.  This is where the “just being with” can be strong medicine.  I cannot do anything to bring her grandson back.  Grief is not a disease, it should not be anesthetized away.  It is a necessary process and part of life.  But it MUST be witnessed.

So, I sat and listened – intently.  I probably didn’t say a true word, just nodded, for at least 5 minutes.  Try truly listening to someone for 5 minutes.  It feels unnatural.  It takes practice and intention.  Doctors are terrible at it – there are studies to prove it.  She cried.  I didn’t try to make her feel better, those who are grieving need to feel the sadness at times.  I was simply being with her while she felt it.

good doctoring can be a drug

After she had told me what she needed to tell me – again, I had never met this woman before – she thanked me for listening.  I recommended she meet with the pastor and talk about her grandson and gave her a prescription of cetirizine, to see if that helped – knowing that what she really needed was more people to bear witness to her grief and help her feel it, in a healthy way.

Today, I was able to be that person, because I don’t have productivity targets, because I am payed by the hour to simply “be” at the hospital and do what must be done.  That is not the norm in our system.

Even in my current situation, it is simply possible.  It is neither encouraged nor supported. For those of us who try to help people heal through our doctoring, that very act of “being with” is now an act of rebellion.  “Being with” ill and suffering people, when done frequently enough is now a fireable offense in the American Hospital-Pharmaceutical Complex – a.k.a.: not meeting productivity.

I emerged from that room cloaked in her grief.  For a short time, I had wandered the wilderness with her.  It felt meaningful and worthwhile; still, I was drained.  I had a moment of gratitude, because I hadn’t had to choose between “falling behind” and “being with.”  I had the time and energy to give to her and gave it freely, not begrudgingly.

Sadly, this is not included in the “standards of care” in clinics around our country.  As I got into my car to start the lonely drive home, I grieved for all people, patients and doctors alike, who are routinely wounded by our system.