What is Adulthood?

The tumultuous diversity of America is great gift.  Our dynamism as a country surely depends on the constant exposure to new ideas and ways of thinking.  On the other hand, it comes at a cost, too.  Community cohesion seems to be the cost we are paying for this wonderful engine of our country.

One of the binding forces of community is ritual.  Traditional cultures have rituals for all major life events.  These rituals bind us to one another and help us feel rooted in our people and place in the world.  One such ritual I often feel is missing in our culture is that of passage of into adulthood.

I think many of us reach adulthood at different times in our lives.  Clearly 12 years old is no longer the time for recognizing our transition into adulthood.  Yet, I think clarity would be helpful.  Those of us in Medicine often seem to have a prolonged entrance into adulthood due to the many years of schooling and training.

When did I become an adult?  At 18?  When I graduated college, or medical school, or residency?  Maybe, for us Millennials, the transition to adulthood happens when you have to start paying off your student loans?  I had a long slide into adulthood, slowly gaining more and more responsibility.

A little ritual to mark a moment might have provided some clarity.

Is responsibility what marks our transition to adulthood?  I am not so sure.  I always had a fairly large amount of responsibility, often more than my peers.  Yet, it did not make me feel more “adult.”

Growing up, adults are the ones who have the answers.  They teach us the rules of life.  They provide structure and certainty to young, expanding minds.  I know more thing than I ever have, but often feel like I have fewer and fewer answers to the questions which matter.

I still don’t really feel like an “adult.” I certainly don’t feel like I can offer anyone else any certainty.

Feeling Old

Yet, I do know what it means to feel old now.  Unlike adulthood, I learned what feeling old feels like within a matter of 2 months.  After the first, burning, searing weeks of grief gave way to a smoldering, tired blanket of grief.  Our first daughter dying made me feel old.  All of the sudden, I was world-weary and inexplicably brain-and-soul-tired.

It seemed as though the world had gone gray, and taken me with it.  Everything took more energy than it had before.  Then, the hospital-pharmaceutical complex came and demanded I keep performing my RVU tricks.  Any hope I had had of finding some comfort and solace in work and my supposedly noble profession was dashed.

I have hurt more deeply than I knew possible.  Yet, life keeps going.  Now, I visit my grief at times.  Sure, sometimes I feel guilty I can not feel it for a few days to even a week at a time.  Sometimes, when I feel guilty about having joy and pleasure in life again, I got back to the day we had to say good bye.  I remember holding her as she stopped breathing.  Soon, I am softly crying, and I know I haven’t stopped feeling her loss.

The grief of losing my daughter was by far more painful of the two wounds I sustained at that time.   No one should have to lose a child, but people do.  Sadly, it is more common than many realize.  A path exists, there are books, and people want to be supportive (even if they are often bad at it).   Maybe because of this, I have found the process of coping with her loss and healing from it to be simpler, if not easier, than coping with my disillusionment with Medicine.

You Can’t Turn Back The Clock

The repeated grief of coming face to face with my disillusionment with a calling I had had actually grown to believe in seems to be never ending.   The Hospital-Pharmaceutical Complex seems to take joy in reminding me of its callousness and love of profiteering.  It never fails to slip comfortably under the already low bar where my expectations are.

While I have come more to terms with the reality of modern doctoring, it still makes me sad.  Sure, sometimes I am angry, too.  But really, it is mostly sadness.  I don’t have the energy to be angry at a giant faceless industry.  That sadness seem to be the well which feeds my feeling of elderliness.

Before, I felt like I was participating the arena of Medicine.  I was an eager young pupil, ready for action. Now, I view the going-ons of all the little hospitals as an old man on a bench dispassionately watches a cat stalk a squirrel in a park.  It is a drama, but a small and distant one, separate from the man’s life.

Sure, it will be sad for the squirrel, but the world is simply this way.

Welcome to Adulthood

Maybe, I wonder, this is what adulthood is.  It is not rituals, nor accomplishments, nor financial responsibilities.  It is the world teaching you it is not a place of endless possibilities, at least no longer for you.  Is adulthood the place and time where we realize life can be just as cruel as it is wonderful?

Do we become adults when we transition from an excitement about how the world could be to a acceptance of how it is?  No longer the young revolutionaries, we become harnessed bureaucrats and accept our fate?

Maybe then, I was lucky to make it to 32 before I became an adult.  I had a long and wonderful childhood, full of joy and discovery.

On my better days, I hope to return there.

Maybe that hope means my transition to adulthood isn’t so foregone, after all…

 

Is This Path Sustainable?

I suffer the curse of rumination.  I ruminate, overthink, and ruminate some more  Strangely, I don’t tend to worry all that much, but I think on things, repeatedly, and often.  My ruminations have a tendency to make the simple complex, the joyful a morass of conflicted emotions.

A recent drive home across the Big Empty was fertile grounds for such rumination.  I had completed a 78 hour shift on the High Plains.  It was an easy shift.  I saw 10 clinic patients, 5 ED patients, one of which I admitted to the hospital.  None of it was particularly complex nor emergent.

For that amount of work, I made roughly 1/2 the salary that most outpatient family docs make in a month.  That is right, for 15 patients, I made about over a 1/3 of my income for the month.  You would think I would have been driving back home thinking about how I lucky I am to have found such a gig in modern medicine.

Instead, I became what my wife terms “thinky.”  I couldn’t help but feel somewhat guilty.  Imposter syndrome quickly followed the guilt.  Is someone going to figure this out and get rid of this?  What will I do then?

This clearly is not sustainable for the country…Is it sustainable for me?

The Stories We Tell Ourselves

Obviously, from a financial standpoint, I did not generate enough income from my physician fees to justify what I was paid (not to mention what the company I contract with got paid). I generally justify what I get paid with this knowledge:

The hospital pays me to keep the ED open, not to generate revenue. 

It is true, of course.  And a true free marketeer would simply say, “If someone will pay you to do it, it is the market’s will.”   A lot of people don’t want to do what I do, so my willingness to do it is worth a high price.

It may just be that simple.

Nonetheless, I often still feel like a profiteer.  My services are expensive. I can’t help but wondering why someone hasn’t figured out how to avoid using me.

Of course, this is not my problem to solve.  Plenty of people are paid quite well to manage these little hospitals, and if they can’t figure out a better solution, why does it bother me?

I keep speeding along open highway…

I stare at the prickly poppies in the ditch as they race past fenceposts along the green and tawny plains.  I can feel my brain chewing its cud.  The anxiety behind the above question is, of course, what will I do if they do figure out something better?

It is a real, yet remote anxiety, I turn down work every month.  There is too much need on the High Plains to fill.

How is there still so much work available that I am constantly turning down shifts?

Of course, I know the answer.  The High Plains are not for everyone.  It is tough country.  There are no beaches nor ski resorts to attract and retain doctors like resort towns have.

Moreover, hospitals tend to ask more and more of their staff until they quit.  Succession planning is not in the vocabulary.  Rural hospitals live from crisis to crisis. Part of this is the natural result of having shallow benches.

If a town only has 3 docs, all it takes is for one one to get sick, retire, quit, get in trouble with the medical board and you are suddenly asking your docs to take every other day call.   The call schedule for the rural Emergency Departments is like Jonathon Edward’s God:

The God that holds you over the pit of hell, much as one holds a spider or some loathsome insect over the fire, abhors you, and is dreadfully provoked;

-Jonathon Edwards, Sinners in the Hand of an Angry God

The Rural ED Call Schedule takes but a faintest provocation to throw the lives of its participants into absolute chaos.  It only knows how to ask for more.  Living, day in, day out, under the guillotine a rural ED call schedule is knowing your kids’ games, family dinners, trips with friends all hang in a delicate balance.

They could all be lost at a moment’s notice.

It is not for the faint of heart.  It is also a stress which the non-clinician cannot know.  Managers of rural hospitals ignore the psychological effects of living under that cloud at their peril.  Unfortunately, most do and turnover is constant.

As long as a cost-based reimbursement continues to be a policy of Medicare, I will have more work than I know what to do with.

Cost-Based Reimbursement, the Lynchpin

I have mentioned cost-based reimbursement before.  It is absolutely the only reason Critical Access Hospitals are able to use me and not go broke.

The basic tenet of Cost-Based Reimbursement(CBR) is that for a given hospital stay in a Critical Access Hospital, Medicare will pay 101% of the “cost” of providing services to that patient.  Who gets to decide what is included in that cost?  The hospital.

So, because my fees can be included in the cost of providing an inpatient stay, they can be written into the CBR formula.  Of course, if I am in the ED seeing a bunch of patient’s, this cannot be included in an inpatient cost report.

So, hospitals have to report how much time a physician spent on an admission, rounding, other inpatient tasks.  Then, they can roll that percentage of my fee into their cost report and get reimbursed for it.

In short, without cost-based reimbursement, I would likely be out of a job.

Though I am technically a “business” as a 1099 sole proprietor, my entire income hangs on government spending at its root. This is the reality of most of healthcare in this country.  Sure, some people have private health insurance, but public healthcare spending is what keeps the lights on around this county’s hospitals.

We would do well not to forget that.

So, is it Sustainable?

I decided to write this post for one reason, to break my rumination cycle.  Sometimes, putting thoughts down on the blog helps release them.  The reason a cycle keeps going because I have no definitive answer.

Clearly our current healthcare system is unsustainable.  Cost-based reimbursement may be as well.  However, I am hardly alone in making a very good living off the healthcare system without necessarily adding that much value.

On the other hand, rural locums is common in plenty of other countries with systems less screwed up than ours (New Zealand, Australia, UK, and Canada).  So, this might be plenty sustainable.  Like every thing else in healthcare, we all know it can’t keep going like this forever, but it might go like this long enough for me to finish my medical career.

I guess this is gig will be sustainable until it isn’t.

Featured Image:  Path in the Forest.  Spruce Forest.  Ivan Shishkin, 1880.

Can Physicians Resist? Or Only Vote with Our Feet?

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

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

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

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

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

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

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

We don’t know how to Resist

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

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

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

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

Debt, Competition, and Greed

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

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

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

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

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

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

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

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

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

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

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

Is There Another Way?

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

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

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

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

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

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

Surviving the healthcare industry has sadly become our goal.

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

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

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

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

The Psychology of My Debt

My debt weighs on me, both financially and psychologically. Interestingly, this was not the case in medical school or residency. Then, about 3 months into my first job its specter began to grow, even though the actual number started declining for the first time in 7 years.

Overtime, the psychological importance of my debt balooned in inverse proportion to the speed at which I was paying it off. I would spend hours per month tracking it, trying to find ways to pay it off faster.

I stared at the screen, as if by sheer will I could reverse the nature of compound interest. This did not work.

This was always going to be a bad thing for me, psychologically. Money has never motivated me. Having more money has never made feel better about life or myself. It felt unnatural to be so concerned about numbers on a screen. It just wasn’t me – but I couldn’t stop.

Turns out, having lots of money won’t make you happy, but owing lots to someone else can make you miserable.

My wife tells me sometimes our marriage feels like a terrible love triangle between me, her, and my debt. Yet, after leaving my first job, the problem did not improve. It actually worsened.

We took a significant hit in income and any hope at loan repayment went away with transitioning to 1099 work. I felt the pressure of paying off the debt land squarely and intensely on my shoulders. I focused all the energy I had previously given to medical training onto paying down my debt.

It had become my white whale.

Obsession is Never Healthy

At first, I had assumed my debt weighed on me because I hated my first job. I had jumped from the cloistered, privileged, insincere nobility of academic medicine into the cauldron of RVUs and the greed driven Hospital-Pharmaceutical Complex. The disillusionment was scalding.

More disturbingly, my partners were lining up at the trough to eat the unethical slop. The system was playing them like fiddles, and they were happy to oblige. Never mind the fact they were actually miserable.

Yet, they played the part of selfless, caring physicians – even if all we ever talked about at meetings was how much money they could make. I felt tainted by association. The guilt gnawed at me.

That guilt did not immediately go away upon changing to my current locum tenens work, it morphed into a different kind of guilt. I felt guilty for abandoning the noble aim of continuity of care and my former dream of being the “local doc.”

So, my obsession grew, despite changing my work situation.

Kids Change Everything

Having our second daughter gave me a chance to refocus. Having a family has changed the relationship I have with medicine again. I have slowly been able to let go of some of the anger I had at the way my partners and health system treated me.

I had directed a good deal of that anger at the institution of medicine. I have since come to realize it isn’t particularly helpful to hold an amorphous profession accountable. I will never be able to have closure with a profession.

I have also released myself of my burden of accountability to the profession. If the profession is not accountable to me, I am not accountable to it. This has greatly improved my relationship with work.

I have managed to lower my bar for satisfaction drastically. My relationship with medicine has evolved from complete devotion, to resentful hatred, to a simple acceptance.

This evolution has allowed me to see how much power I was giving my debt over my life.

We Give Things Power over Us

Most people seem to have the problem of not realizing how detrimental debt is to their financial health. I had the opposite problem, I gave my debt complete control over my enjoyment of life.

I had made eliminating my debt into the dreaded “next step.” That next accomplishment I had to reach before I could be happy. Even though I knew that trap all too well, it had caught me again.

Debt had become a binary state. I was either in it or I wasn’t, progress did not exist. And, as long as I was in debt, I was beholden to medicine. And that pissed me off.

Eventually, I realized it had gone too far…

Around tax time, I was able to throw a huge amount of money at my debt. As this was the first year I have been paid substantially as a 1099 sole proprietor I apparently had over-saved substantially for my tax bill. In one fell swoop, I eliminated over 15% of my remaining debt burden.

But, I was not pleased. Instead of congratulating myself on making large progress in eliminating debt, I was emboldened to try and move up the timeline on making myself debt free.

I felt the need to pay more faster because I had made so much progress so quickly. I knew this was not a reasonable reaction.

I was chasing the dragon…

I had something to decide. I could continue to be angry and resentful for 2-3 more years and hope it got better when I paid off my loans (the go to doctor coping mechanism). Or, I could actually wrestle with my emotions and try to find a way to happier in the present.

Perspective Change

So, instead of continuing to think of my loans in binary terms of being chained to or free from medicine. I asked myself a bigger question.

“If I had already paid off my loans, what would I do differently?”

Turns out, probably not much.

I would probably work a little bit less. We would travel more(I hope), probably buy a house. But, most importantly, I wouldn’t quit medicine and try a different career.

This was hugely freeing.

The emotional benefit of being debt free is the idea you could walk way if you wanted to. So, realizing I would not walk away took away a lot of the power of the loans.

Doing The Math

Once I deflated the emotional power of my debt, I could look at it a bit more rationally. I had made a lot of progress. I decided to run some scenarios.

I ran various amortization schedules based on refinancing vs not and at different time intervals (2-5 more years). Instead of the shackles vs. freedom emotional response to debt, I tried to give myself more of a dollars and cents view.

Turns out, depending on various scenarios, my debt will likely cost me another $10,000-$25,000 in interest. Also, it turns out I should probably refinance my student loans.

So, those numbers are not nothing. However, it allows for a more rational conversation about my loan debt. Instead of a binary choice for happiness, I can ask:

“How many more months am I willing to be in debt to enjoy my life more for the net 2-4 years?

Since I am not going to go out and buy a Tesla or mega-house or anything like that, it is mostly about how gentle am I going to be with myself about how choosing to work a little less so I can spend more time hiking, fishing, traveling, etc.

Turns out, I am probably willing to spend up to 6 months more in debt to have more time doing other things I enjoy.

I am tired of waiting for the next thing, I am living right now. 2 years of living a happier, more balanced life seems worth a few more months of debt.

Student Loans: Modern Indentured Servitude

When it comes to my finances, everything else besides paying off my student loans seems trivial. I mean, I am attending physician. We have no shortage of money to survive on.

Nonetheless, 6 years out from my medical school graduation, almost half of my after tax income goes to servicing my student loans. Indeed, I might have quite medicine altogether after my daughter died if not for my student loans

Given that our finances provide more than enough for a comfortable life, all other financial decisions take a back seat to my student debt. Pretty much anything I forego financially is because of student loans.

My student loans are financial and emotional albatross that weigh on me constantly, even when I am not consciously thinking about them. Currently, I am an indentured servant to the medical profession. The debt changes the relationship physicians have with their chosen calling.

Debt is a trap, especially student debt, which is enormous, far larger than credit card debt. It’s a trap for the rest of your life because the laws are designed so that you can’t get out of it. If a business, say, gets in too much debt, it can declare bankruptcy, but individuals can almost never be relieved of student debt through bankruptcy.
-Noam Chomsky

The Long Road to Freedom

I prioritize paying off my debt above all other significant expenses. This has led to some significant improvement in my student loan balance. This has tracked about like this:

Graduate from medical school: ~$285,000 principal + interest.

6 months later, interest capitalized: $330,000 principal.

Finished residency: $330,000 principal+$65,000 interest=$395,000.

Currently, almost 3 years out from residency graduation: $188,000 principal+$30,000 interest= $218,000.

So, progress is being made. On the other hand, it comes at a cost. I have avoided contributing to the economy in significant ways because of my debt.

Some are basic consumer activities which I am more than happy to forestall. These include buying newer cars, new furniture, etc. These thing bring me little to no happiness, so foregoing them is not a sacrifice. The economy might miss those purchases some, but relatively little.

These, on the other hand, are significant:

  1. Saving for retirement: Back when I was employed (W-2), I took advantage of my employer’s match and maxed out my 403b. However, now with SEP-IRA which has no match, I still contribute, but at a much lower rate than maxing out (partially because the max is so high relative to my income (>50,000). The 6.5% guaranteed return on my debt is hard to dismiss.
  2. Home ownership: we tried this, got lightly burned. We will probably rent for a total of 3-4 more years before we try and buy another house. Another significant investment in the economy delayed.
  3. Pursuing activities other than working and finances. I have to focus a great deal of time and energy on paying down debt. So much so, it sometimes feels like I am in debt residency. I read about finances, scheme on ways to increase my debt payments, etc. Sometimes, it leads to neglecting other parts of my life.

Who Cares?

A reasonable response to my hand wringing over my debt is, indeed, “Who Cares?” I am in no way living in destitution. I will, in the next 2-3 years be able to pay off my debt entirely without any real deprivation (we live on about $90k/year for a family of 3 – very comfortable).

Additionally, one could point out I went to medical school knowing what it would cost and was not forced to accept loans in exchange for education. This is also true.

Moreover, what will likely end up being a total $500,000 investment will have moved me from a childhood of living on about $50-70,000/year in today’s dollars with a family of 5 to 4-5x times that income/year. I was never going to be an investment banker, tech entrepreneur, or engineer, so it is unlikely I would have made that jump in income any other way.

If you feel these things, that is totally legitimate. I do not need anyone’s pity for my financial situation, but you might want to stop reading now.

On the other hand, if this affects a privileged actor in the economy such as I, imagine how it holds the lives of less privileged students hostage.

Paying to Play in the Modern Economy

This plays out in the broader economy. We have placed increasingly expensive layers of education in between poverty and opportunity.

This is key.

The increasing cost of education and student loans, in particular, have made opportunity only available to the wealthy and those willing to live a good portion of their lives in indentured servitude.

I want to emphasize this point: for a huge number of students the price for the access to opportunity can only be paid with student loans. They do not represent an investment with a guaranteed return, but the only the opportunity to collect.

On top of this, unlike almost any other business debt, educational debt is non-cancellable. For example, I know someone who started medical school. Her mother got cancer when she was in medical school. She was able to finish, but with great difficulty and still has not been able to start residency. But her debt keeps accumulating interest….

In any other business situation, if you took out a loan to invest in a business and something terrible happened, you could declare bankruptcy and at least get back to zero. Educational debt just sits there, continuing to accrue interest despite your inability to collect on the investment….for the rest of your life.

Medical Schools Hold Abnormal Bargaining Power

Medical schools have disproportionate power when negotiating with potential clients (students). They are the gate keepers to a prestigious and historically wealthy profession.

What bargaining power do individual students have?

The average age of beginning medical students is 23 years old. Many of them have spent close to a decade striving towards medical school admission. Every physician they know has taken on loans to become a physician, so who is going to say no?

Are the risks of being unable to repay your loans explained to first year medical students before they sign on the dotted line?

I think not, because medical schools don’t care.

As long as medical students graduate, they don’t care about their debt. They just want all four years of loan payments.

It is inaccurate to say medical students really understand what they are getting into when they accept loans. For instance, I think few understand the cost of the interest compounding while they are in residency.

Moreover, no first year medical student knows how long they will be in residency. So, it is literally impossible to know what the cost will end up being when beginning medical school.

However, no student agreeing to take on loans can understand how the yoke of student loan payments will make them feel. The way it might weigh on their lives for 10-20 years. That can only be experienced and doesn’t have a cost measured in dollars.

Still, most physicians with discipline, and some luck, can pay off the loans relatively quickly.

Student Debt will have Long Term Effects

Beyond the specifics of my or any physician’s experience is the reality of student debt becoming a giant drag on the overall economy.

As a society, we are trading a large prolonged stimulus to the higher education sector in exchange for a significant drags on future productivity and consumption.

Moreover, we have provided the education sector with a way to be almost completely cost insensitive. In the days when state and federal dollars made of the bulk of their budgets, public universities had to be cost sensitive. Now, they just increase income from students, almost overwhelmingly from student debt.

We expect the most financially vulnerable of our population (young students) to enter into lifetime binding contracts with these institutions.

Meanwhile, where are they getting most of their financial advice?

From these institutions themselves, whose main goal is to keep up their class sizes. They certainly don’t have the long term financial health of their students as their primary concern.

We have yoked an entire generation with the personal responsibility for our penchant for deficit spending.

Back to My Indentured Servitude

A colleague of mine who paid off his student loans with hard work and sacrifice told me, “I am so glad I did, it has completely changed my feeling about practicing medicine.”

He gave voice to what a lot of young physicians know: their ability to get creative, tack risks in business, and try and improve the healthcare system is hamstrung by the need to get out of massive debt.

The Hospital-Pharmaceutical Complex has been very adept at exploiting this as a way to keep a churning stream of physicians willing trade their profession for escape from financial bondage.

As for myself, we are yet to see if it turns out to be worthwhile investment. I could have been earning income and saving for retirement since my mid-late 20s instead of accruing debt. It largely depends on how long I work as a physician.

Luckily, I have found a practice arrangement that I can imagine working in for quite a while. The freedom to take a couple of months off from a particular working environment has greatly extended my working life.

2 years ago I was thinking about trying to FIRE like so many physicians and possibly switch to a non-clinical job in the process. Now, as long as I get my debt paid off soon, I can imagine a reasonably lengthy time career as a physician.

However, not all physicians are so lucky, and most non-physicians don’t have anywhere near the options physicians.

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.

Who Built This Leaky Ship?

People who don’t use it, that’s who.

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

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

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

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

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

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

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

Welcome to the Norm

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

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

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

Search satisfaction is a strong bias.

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

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

So, who came up with this crazy system?

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

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

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

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

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

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

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

Is there hope?

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

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

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

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

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

The Hard Work of Doing Nothing

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

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

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

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

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

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

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

The reason for the visit finally comes out

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

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

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

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

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

“I can tell, Ed.” I agreed.

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

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

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

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

Primary Care – Psychiatry without the time.

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

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

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

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

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

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

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

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

I was not shocked.

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

Bison – wisely doing nothing. Photo Credit: NPS

Why Can’t We Do Nothing?

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

Never mistake motion for action. -Ernest Hemingway

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

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

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

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

Being still might be the hardest thing

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

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

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

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

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

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

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

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

How the Corporatists Stole Quality

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

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

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

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

Clinicians Don’t Decide

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

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

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

I can be a team player.

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

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

Low-liability care is not quality care.

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

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

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

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

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

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

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

How did we get to this point?

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

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

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

Systemic problems rarely have individual solutions.

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

Uh Oh, I Want to Fix Things Again…

feeling the burn, again.

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

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

problem 1 – working too damn much

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

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

problem 2 – location monotony

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

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

Summary:  an emotionally draining patient population.

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

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

in the nomadic world – freedom is all

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

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

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

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

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

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

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

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

here’s the rub, i like fixing things

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

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

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

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

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

getting singed

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

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

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

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

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

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