Our Sacred Grief

With nonessential procedures and medical visits postponed, an eery quiet has descended on hospitals on the High Plains. The surge is not yet here, and the curve, thankfully, appears to be flattening.

It is, however, the quiet of an undisturbed bowstring. Taut and tense under pressure, yet ready to snap. Most of us have tried to lose our anxiety in work, yet work provides little respite from the anxieties of this moment.

I am awash in time aplenty to catastrophize and perseverate on my anxiety regarding our current pandemic. I am thankful not to be sick. I am thankful not to be doing battlefield triage on people’s grandmother and grandfathers.

Yet, the time means I am awash in stories of others’ grief. Of people losing children, parents, spouses, siblings. All tragic, some seemingly more so than others.

The stories of young parents and children lost strike me the hardest, of course. The distance all too small between them and I. There but for the grace of God.

I Know This Valley

While my own grief is not in the front of my mind anymore, I know it is not gone. It sits on a shelf in my soul, perfectly undegraded.

Occasionally, I pick it up in my mind, dust it off, and the pain of it comes rushing back. I reminder of love as well as pain. As I read stories of other’s grief and know of how much more grief is yet to come. I feel their pain reflected off my own preserved grief.

Even moreso, I feel the pain of their loneliness. I think of the thousands of people who, panicked and in fear, kissed their love ones good-bye in the ambulance or at the ER door. They watched gloved and masked helping hands carry them away, desperate to see them discharged safely from the hospital in few days.

Yet, too many will never hold them again, never see them again other than through a camera lens in an App. They will grieve at a distance, knowing that somewhere, their loved one’s bodies have been hermetically sealed and placed in refrigerated trucks, waiting to be taken somewhere else.

I know the pain of holding my daughter and watching her take her last breaths. Yet, no matter how painful that was, it was better than not holding her, not carrying her around the house she didn’t get to grow up in.

I am reminded of stories of how grief changes when the world is turned upside down. During WWI, Russian villagers would have a funeral for any young man called up to the front from their village before they even left.

As a teenager, this story simply seemed really sad and evidence of how likely death was in the Great War. Now, I also see it as an attempt to maintain something human in the midst of inhumanity.

Better to grieve together and be wrong than to never get closure.

I can only imaging the anguish of not being able to grieve next to all who also loved your beloved. So, this disease steals not only lives, but the opportunity to grieve together, to say good-bye in an embrace.

Why Do We Grieve?

When I was struggling with my grief, I did what I always do when I don’t feel prepared. I read about it. I am an intellectualizer to the core.

I read multiple books and grief and grieving. A question I had never asked myself, but which exists in the literature is a simple one:

Why Do Humans Grieve?

Grief extracts such an intense cost, personally and communally. Some literally die from it. What could be the evolutionary basis of such a thing?

I found a few posited answers to this question, none with good evidence. One was that grief shows the community or future mates the intensity of the bonds you form.

This didn’t really hold much water for me.

The one which resonated with me was that grief serves to bind a couple, family, or community closer together. Not only in sorrow, but in love for the who or what is lost. It is a sacred function of grief. When we grieve well, we grow richer in love for everything.

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

-Khalil Gibran

What strikes me is how, on a physical level, COVID will deny many of us the opportunity to participate this sacred aspect of grief. I literally cry thinking about it.

Yet, the lack of that connection in the moment also amplifies a need for community, for humanity on a much larger scale. A time will come when contagion no longer separates us from each other. We will hold hands and embrace again.

We must remember to take that opportunity and hold it with the weight and reverence it will have earned. All of the death and loss will give us a gift. A gift of communion in pain with more people than we have ever met. Our local, national, and international loss has the power to bind us together in sorrow and love, if we let it.

Every one of us will be touched by this event. We must not slide into comparison and recriminations as a people, but join together in a collective wail of wild grief and love for what we have lost, but also with whom we are will be so blessed to remain.

Grief is pain, yet it is also a gift, because it can only come from love. I hope we do not waste the gift this plague will bring us.

Photo: Grief, by Oskar Zwintscher, 1898.  Work created before 1925 and public domain in the U.S.

The report of my death was an exaggeration


The report of my death was an exaggeration.

-Mark Twain

Yep, not dead. Not even internet-dead. Although, since I don’t have an Instagram account, I think I may have never been internet alive – technically.

I am still practicing medicine roaming the High Plains. I just stopped writing. Not even on purpose, at least if I had done that I could say I had made a decision. One day, I didn’t post anything, then another, then another, then suddenly it had been weeks.

Writing is hard, doing it consistently is even more difficult. More specifically to my situation, things have just been better. So, I have less to process and complain about on the blog. Or, I should say, my life has been better.

Having a kid who can breath on her own has turned out to be pretty awesome. It also means I am busier than I was and something has to take a bit of back seat, e.g. the blog. Moreover, we have decided to buy a house, so I had been working more to save up for a down payment.

I still kind of feel like buying a house is a big scam, but, I would really like to plant some fruit trees and grow more of my own food – much easier when you own a piece of land.

It also seems to make more sense when you have a small child. Having a kid doesn’t mean you need to buy a residence, but somehow it makes doing so seem a little more logical.

The Bitterness Subsides

On the other hand, medicine is a still an FOS crazy train barreling towards a bridge the Wile E Coyote of corporate healthcare waiting to blow up.

I am just more ambivalent about it all.

At one point, I felt a burden to make healthcare in America better. It drove me crazy to think how terrible it all was. How the incentives were all misaligned. The way we harmed people through overtesting, overtreatment, and overprescribing on a daily basis appalled me.

All the while treatments which could actually make a different in people’s live are not available to huge numbers of people because of our terrible health insurance nightmare.

Yet, anyone can score some oxy or sildenafil without much finagling at all, legally. And usually get some or all of it paid for.

I have come to accept my smallness in this shitstorm. I have also come to accept the sad fact that a lot of people would rather have the shitty system we have than risk a different system or especially risk changing their own lives to improve their own health – physical and mental.

Occasionally, I do something noble and decent as a physician. Usually, I am just moving people’s problems around and giving them pills to treat the physical symptoms of a broken, lonely, and self-destructive society.

We seem to prefer it that way. Better the suffering you know….

Settling Down, Kind of

So, with my life outside of medicine improving, and my expectations from medicine having decreased significantly, I have decided to settle down – kind of. As I said above, we are buying a house. I will continue to travel for work, but mostly to the same location.

I have signed a contract to work as a staff physicain with one Critical Access Hospital 80% of the time. I have worked with them off and on for the last year. It is a low volume place with a good set of local staff. It has very few resources, but a rather pleasant patient population.

We will not, however, be moving to this town. Once bitten, twice shy. We may end up splitting time for a while. We may even move there eventually if it all works out. I’ll spend 2 nights a week there and give it a shot.

You might ask, why travel out to the middle of nowhere when there are plenty of good suburban urgent care or PCP jobs available closer to home?

I will make more in this new gig that I would in the City practicing 5 days a week as a PCP. I will even possibly be able to access some loan repayment. And the volumes I’ll see would be laughably small in a City. I’ll get to see patient’s in the ED, Hospital, clinic and NH. So, other than delivering babies, will be able to keep my skills up for the most part.

Chief Complaint – R foot swollen, hurts.

But mostly, it is because of stories like this:

I was working at this location a few months back and this older man comes in to see me in clinic.

Chief Complaint – R foot swollen, hurts.

Walking in the room, I see my MA has exposed his right foot to the knee. It is swollen, red. It looks painful. The remains of a homemade bandage lie on the floor next to the foot covered in dried blood and pus.

So, Mr Banks, what happened here?

I cut the bottom of my foot on the screen door three days ago. The day or so has been swelling, getting red. Hurts like a sonofabitch now.

I bet, let me take a look.

I bend over and look at the bottom of his foot. There is a 4 inch gash at the base of his right small toe down to the tendon. Shockingly, his toe’s movement and function is fine. Red, swollen, cellulitic skin surrounds the wound and streaks up his leg. A golden crusty discharge of a staph infection frames the image.

I lean back and sit down. Well, Mr Banks, it is definitely infected. Unfortunately, even it weren’t infected it has been too long to close it with sutures, so we’ll have to let heal on its own. Given the how bad of an infection it is, I think we should have you in the hospital for a day or two on IV antibiotics…

Hold it, he interrupts. I am not going into the damn hospital. I’ll take some antibiotics, but I am not gonna be in the hospital.

I startle a bit. My normal experience is people trying to convince me they are sicker than they are and need more pills, treatments, nights in the hospital than I think will do them any good. I pause and look him in the eyes. Well, I say, let me think about we can do.

After a bit of creative restructuring, I pitch him this plan.

If you’re willing to come to the hospital twice a day for a couple of days for wound care and IV antibiotics as an outpatient we might be able to work something out.

I am not crazy doc, I’ll do what I need, I just don’t want to be in the hospital.

Ok. We’ll check a CBC and CRP daily and a Vanco level every 2 days, make sure the infection is improving, and then transition him to oral antibiotics.

I can handle that, doc.

I write the outpatient orders for the hospital nursing staff and set him up for clinic visits for the next two days. These will physically take place in the hospital outpatient ward, but will be billed as clinic visits.

In 30 minutes, I have set up an outpatient hospitalization for this man. Medicare has saved a huge amount of money. I will see no benefit. No financial incentive exists for this kind of care.

I was meeting the patient in the middle and get him the care he needed.

I know of no other setting where a clinic doc could arrange this kind of creative care without a huge outlay of time and energy.

This poor doctor would still probably fail in the end. Angry patients would then punish her for being late. She would sacrifice time at home with her family to more charting. Yet, it was possible for me to do this fairly quickly at a Critical Access Hospital.

Sure, it was a little more work, but not an absurd amount. Honestly, it was less work than a hospital H and P and medication reconciliation plus a discharge summary at the end.

This is why rural medicine pulls me back in. There is still a place for creativity and bending the possible on the High Plains. I am not sure for how much longer, the corporations are at the gates.

But, very little money grows in the Big Empty, so they may just stay at the gates for a while longer.

Photo Credit: Mark Twain, by AF Bradley, New York, 1907.

Special Shout out to Dr. Mo, his recent post lit the fire under my rump to write another post.

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.

Rural Medicine: Reaching the Limits

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

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

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

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

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

Making Do

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

This hospital does not even have the robot.

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

Finally,  tech X-ray tech arrives.

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

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

The bed scale registered an astounding 472 lbs.

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

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

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

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

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

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

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

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

We sent her by ground ambulance as quickly as possible.

We Don’t Have That

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

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

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

“We don’t have that.” I am told.

“Fosphenytoin?”

“Umm, I don’t think so.”

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

“I don’t know, maybe ketamine?”

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

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

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

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

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

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

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

Somewhere with a functioning ventilator and some damn Keppra.

I looked around that the remaining EMTs and nurses.

“Well, that could have gone worse.”

Why Do This Job?

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

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

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

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

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

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

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

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

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

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

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

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

 

 

At the Bottom of a Hole

I startle in the windowless sleep room.  My call phone summons me awake.  In the darkness, I reach for and immediately find it.  From week to week, the counties, hospitals, and staff all change, but the phone is permanent. 

It is always there, it has become an appendage.  My brain seems to have proprioceptively grafted the location of the phone onto its neural circuitry.  It has become a permanent part of me in this floating life.

A voice on the end relays the message. “Dr. HP, we have an ambulance coming with a Mrs. Z, complaint of altered mental status, possible seizure.  She’s been in here three times for the same complaint in the last 2 months.”

“Ok, I’ll be there.” a disoriented groan.

Patient Arrived Altered…

I walk into the trauma bay. Family is crowded about their her. She lays in a crumpled pile on the gurney.  Her GCS is 11, so she avoids an intubation.  Nonetheless, she is minimally responsive, completely disoriented, unable to provide any meaningful history. 

From the family, the story unfolds like a jumbled ballad of confused pain and suffering. I hear the frustration about the repeated hospitalizations, the perceived lack of answers, the desperation to help her, etc.  

“She was here three weeks ago with the same thing. She went home for a few days, and then was in the other hospital in county 10 days later, and now she’s back. We don’t get no answers every time we come in.”

“That must be so frustrating and scary.” I reflexively parrot their emotions back to them as I look up and down Mrs. Z’s body.

“They just say it was another bout of seizure activity and increase her meds, but it seems to be gettin’ worse, not better. We just can’t keep doing this…”

“Jane!” I call her name and her eyes pop open. They fix on me in a wild confusion. She looks straight at me, but I get the feeling she registers nothing.

“Where are you?”

“The hospital…” comes the groggy reply. She meets any further questions with drooping eyelids and a nodding head. The nod.

“Squeeze my hands.” I command her. She faintly squeezes.

The verses of the songs are different, yet we all know the melody by heart and the chorus rarely has much variation.  Her life and medical care has become a tilt-a-whirl ride gone awry.  No one seems to know where to find the exit as she whirls about, up and down, in and out of hospitals.

She is trapped in a swirling confusing mess of tests and medications, no one really sure what they are treating. But by God, they will treat something. 

…She was Arousable to Voice…

The old cowboy saying goes something like this: “The first thing to do when you find yourself at the bottom of a hole is to stop digging.”

This is should be the first tenet of treating the chronically ill. 

We all know them, the professional patients.  The people perpetually entangled in the Hospital-Pharmaceutical Complex. 

Invariably, clinicians know these patients better than any others. We’d rather not, though. We cringe when we see their names.  

In clinic, we fear looking at our Monday schedule before leaving work for the weekend. Their name in an appointment slot can cast a pall over the whole weekend.

As hospitalists, our hearts never sink as low as when our pager goes off and we’re told, “Mr. T has bounced back, you admitted him last time.  Same problem.”  Walking into the room, we sit down in the hole.   

We hate sitting in their darkness with them. Because, when we sit with them, we can’t see the way out either. Their presence smacks us with our own impotence.

First, stop digging…

…Only Oriented to Place, but Able to Follow Commands…

Our teachers trained us with cute acronyms for developing differential diagnoses of chief complaints. VINDICATE, VITAMIN C. With the chronically ill, the first three letters should be “I.”

In the mnemonics, “I” stands for Idiopathic/Iatrogenic. Idiopathic – we don’t know why. Iatrogenic – we did this. I find this juxtaposition amusing. The implication of iatrogenesis being close to idiopathic is commonly upheld in clinical practice.

Otherwise brilliant physicians seem to struggle to identify when the cause of patient’s problems are the medical system itself. It seems a kind of heresy to admit our church’s complicity in their suffering.

Yet, when you lean in, comb their histories and medication lists, our fingerprints are always there. The half-hearted attempts at treatment. Another medication added to end a depressing clinic visit, another test to “rule out” some strange disorder before discharging from the hospital.

…In reviewing her med list, I found a great number of sedating medications….

She is definitely altered, but nothing about her looks like a seizure. I review her medications and tick off the likely offenders: gabapentin, baclofen, phenytoin, and, of course, hydromorphone.

“The one that starts with a D.”

She is on a total of 50 morphine milli-equivalents with less than perfect kidneys. She is on this for arm and wrist fractures which occurred several months ago. Well past the acute phase of treatment.

We admit her, she is too altered to swallow medications, we start IV fluids and let her rest, withholding all medications. The medications begin to wash out of her system. Initially, she responds slowly. Once we refuse to give her narcotics unless she requests them, she comes back to life within 12 hours.

None of the nurses, nor myself are surprised.

Encephalopathy Secondary to Polypharmacy

The chronically ill, the products of the Hospital-Pharmaceutical Complex need a different approach. The old mnemonics and work ups start with a faulty assumption. They start with the assumption of originality of complaint, of something new, of a previously healthy person.

The chronically ill meet none of these stipulations. The first questions should be, “What have we done to this person?” followed quickly by “What can I undo?”

After she has returned from pharmaceutical zombie state, I go in to discharge her.

“You’ve been scarce around here. I have seen you since I have been in here.” She stares accusingly.

“I am not surprised you don’t remember me, you were pretty out of it for a couple of days.” I don’t get defensive. Those newly returned to consciousness are rarely polite.

I recommend an aggressive reduction in many of her sedating medications, including her narcotics. Strangely, she doesn’t argue, it seems to make a kind of sense to her.

Mrs. Z goes home. I am not sure she will follow my instructions.

Nonetheless, they seem thankful for a more a logical explanation to her problems than a confusing seizure disorder that seems to get worse despite “appropriate” treatment. For a minute, we stopped digging and the light stopped receding.

Sometimes, a pause in the chronic deterioration seems like an improvement.

In Praise of Collegiality

Working in small emergency departments without any local back up often demands “phoning a friend,” so to speak. I encounter patients who present with findings and disease processes with which I am unfamiliar.

One warm Fall day, I got called in for a kid injured at football practice. Tom was a 16 year old who was hit head on (axially) in a football game. On exam, he had complete numbness and significant weakness in all four extremities.

Strangely, this was only from about 3 inches above the knees and elbows down (not a well recognized anatomic distribution).

Moreover, his CTs were totally normal. I had no surgeons on site, and the MRI is only available 1-2x/week. My next move was in no way obvious.

My questions almost always stem from the vagaries of practicing medicine in the real world and in resource-limited settings. Those limitations often mean the algorithms only get me so far.

On the other hand, I can only imagine how difficult it would be to practice Critical Access Medicine without uptodate and other electronic resources. Thank God for the internet.

So, I phoned a friend.

With Tom, I called the closest Children’s Hospital, I talked to Neurology first who felt he needed an emergent MRI. The neurologist was thorough and business-like. Then, I was routed to the Peds ED Doc, who was similarly helpful and gave me recommendations of immobilization and transfer.

They admitted him to their Neurotrauma ICU, and he made a full recovery without intervention. Diagnosis: Transient quadriplegia, or aka cervical cord neurapraxia. This was a first for me.

This was a neutral phone consult. I get the information I need to help the patient and we expedite his care. Generally, the physician’s at the Children’s Hospital are more civil than most.

In fact, a Peds ED consultant is to date the only accepting physician to tell me I did a good job. The patient was a pediatric DKA. By the time I called, I had fluid resuscitated the patient, the insulin drip was going, and a bag of D10 with 40 mEq of KCL was y-ed in to allow for titration on the 2 hour transfer ride based on POCT glucose testing.

This was the first time since residency a fellow physician had told me I did a good job with the clinical care of a patient. I am not particularly dependent on praise (honestly probably much less so than the average millennial). Nonetheless, it felt damn good.

I was surprised how good I felt being told I had handle a complicated case well. It made me realize how rarely we get positive feedback from our colleagues. And, if I am honest, how rarely we give it.

How much more pleasant would our days be if we battled a dysfunctional and inhumane system with our colleagues rather than in spite or even because of them?

The Normal Experience

Ruminating on my surprise reaction to a little bit of positive feedback, I started to think about my usual experience. After a time, I realized the marker I now use for knowing I did good a job with a transfer is the absence of snark.

If all I get from a hospitalist after I give the report of a patient is a begrudging, “Ok,” I know I have done a good job in setting up a patient for transport.

John’s Story

For instance, John, a 65 year old man with diabetes who had been struggling with recurrent infections of a diabetic wound on an old amputation site came into my emergency department the other day.

Three days prior he stopped his latest round of oral antibiotics. The wound had increased purulent discharge, pain, and surrounding redness. I looked into the putrid hole at the end of his leg, clearly infected.

Moreover, His blood pressures are soft, he was mildly tachycardic and febrile.

“Likely early sepsis,” I thought to myself, a lactate of 2.9 quickly confirms my suspicions. I order a wound culture and blood cultures, fluids, and antibiotics.

After examining the surrounding area, I took a sterile probe and inserted into deep into the wound. It slid past the slimily infected tissue and felt the sure, soft thud of bone at the end of the probe.

“Shit,” I think, “No way infection isn’t in his bone”

“John,” I start, “I think we need to get an X-ray (MRI is of course not available today) to look for infection in the bone.”

The techs wheel him off to X-ray.

Sitting in the reading room, I (the humble ED doc) can clearly see the lytic lesions at the of the bone indicating infection, and the likely need for surgery. My nurse starts the antibiotics and I call a hospitalist at a referral hospital.

I get the hospitalist on the phone. I run through his story ticking off all the important information: Vitals, lactate, white count all point to early sepsis with a clinically infected wound. X-ray showing acute osteomyelitis – he will need a surgeon and long term IV antibiotics.

I detail the care I have already given the patient. I feel he is stable for transfer. Moreover, John and his family requested transfer to the this specific hospital (multiple hospitals are effectively equidistant for transfer).

On the other end, I hear a long pause. Then, the quiet, begrudging, “Ok, we’ll take him.” Those are the last words he speaks to me, switching to addressing the operator to arrange bed placement.

I apparently don’t even merit a good-bye.

The sad thing is, I now interpret this kind of interaction as evidence that I have done a good job. No snarky comments, no prolonged questions and second guessing, no arguments as to why going to some other facility or service would be better.

And I felt good about it. I had won in the battle to deny him any reason to do any of the above.

That is how low my general expectations for civility have sunk when talking to another physician. Moreover, this is a physician with whom I am technically collaborating on the care of shared patient.

Civility is the Grease of Teamwork

Now, the art of the long distance phone consult is a delicate one. I don’t always nail it perfectly. Walking the line of giving someone all the information he/she needs while still making a coherent narrative of why you need his/her help is often difficult.

To boot, my phone call is almost always interrupting some other work the consultant is attempting to accomplish.

Furthermore, as physicians, we all work in high stress environments where it can be difficult to find a moment to focus on the problem at hand. We all have bad days, I get it.

I talk to all sorts of consultants – board certified ED docs in a large trauma center, Peds ED docs, surgeons, OB/GYNs, cardiologists, stroke neurologists, or hospitalists and intensivists for transfers.

I need all kinds of help out here on the High Lonesome.

In particular, hospitalists at large referral centers are slammed with work which is often effectively clerical. I.E., admitting a pre-op hip fracture patient so that Ortho can focus on more important (ahem, profitable) endeavors.

I know civility is rarely at the top of our lists. Nonetheless, I think we as a profession are forgetting or have already forgotten the importance of civility and collegiality.

Afterall, we are all in the game of trying to help sick people, together.

If I am uncivil to a nurse who is caring for a patient of mine, he/she will avoid calling me. If that patient crumps when we could have avoided the situation, I need to take some responsibility for that outcome. 

Civility and collegiality are the social tools we have to reframe our interactions from oppositional to collaborative. Without them, our profession splinters and we are all little Lone Rangers fighting our own pitched battles day in and day out.

So, I for one am going to try and put a little more civility back into my interactions. It costs me nothing, and I have found more often than not, it pays dividends over the course of the conversation.

And, most importantly, my patients get better care when their physicians collaborate with, instead of battle against, each other.

Bad Financial Decisions I Don’t Regret

financially deleterious decisions in hindsight

Many physician and non-physician finance bloggers share their financial stories and their mistakes.  Xravzn’s story of trials, tribulations, and the financial decisions he had to overcome was particularly inspiring for me.

Financially, the first two bad decisions dwarf the rest:

  1. I went to possibly the most expensive medical school in the country (this might end up being about $500k by the time I pay it all off)
  2. I did not choose a particularly high paying specialty (Family Medicine averages 180-250k/year)
  3. Buying a house within a couple of months of starting my first job, having already figured out that we weren’t going to stay there for more than a few years.
  4. Taking a three month trip through Paris, Spain, Morocco, England, and Iceland in between residency and starting my first job (probably about $20,000).
  5. Going on a 4 week trip to Odessa, Ukraine and Bulgaria with my now wife, brother, and mother in my 4th year of medical school ($4,000 of student loan debt funded that adventure)

Could I have made some smarter moves with investments, decreased costs, etc.  Sure, but none of them compare to the first two on the list.  They are rounding errors in comparison.  Do I regret these decisions?  I am not sure.

#1 – Expensive Medical School

I certainly wish I had less student debt, but I met my wife where I went to medical school, which was her hometown and where we now live.  My wife gave brith to our daughter, whose loss has brought us even closer together.  I never thought I could love someone so much, so the debt doesn’t seem that important when you phrase it that way.

#2 – Low-Paying family medicine

As far as my specialty goes, I have mixed feelings.  Would it be nice to be able to pay off my loans faster, yes.  On the other hand, rural family medicine docs are in such demand that job security is not really a concern for me.

Indeed, my current position allows me to turn traditional family medicine (low acuity emergency department, inpatient medicine, as well as clinic) into shift work.

I get paid by the hour – 24 hours a day, often when I am sleeping overnight.  this means I can make 1/2 of a normal family medicine doctor’s months salary in 5 days of straight call in some of the locations.  I might see an average 7-12 patients (ED, Clinic, and IP combined) per day at these particular sites.  Unlike a busy ED doc, I am usually seeing only 1 patient at a time.

I have complete veto power over my schedule.  I often work a total of about 10 days/month currently.  It is a pretty chill lifestyle.  This is made possible by my low paying specialty which is in short supply.  If time is the currency of life, this job pays pretty well.  So, I consider it a wash.

#3 – buying a house

I do actually regret this one.  On the other hand, I am not sure I had many other great options.  We moved to an area dependent on tourism.  Many of the rental properties had been bought up to use as short-term rentals.  Long term leases were difficult to come by.

We ended up buying a house on 5 acres that bordered public land.  It was pretty sweet.  By urban standards, it was very affordably priced and well within our price range.  We moved after 13 months.  Luckily, it appreciated about 5-10% in that time, so we only lost about 10% of our down payment plus the $6,000 we had to pay rent and a mortgage.

Looking at it a different way, my wife and I realized that we don’t like spending a lot of time and energy on our house.  Cleaning a large house was a pain in the ass and neither of us enjoyed it.  Finding out that you don’t want to own a large piece of property early in life is probably worth a lot of money and headache in the long run.  So, I even found a silver lining here.

#4 and 5: Travel with people you love

These trips were worth every goddamned, interest-bearing penny.

Have you eaten grapes and brie with a warm baguette under the shade of the chestnut trees next to the canal St Martin on a warm, summer Paris afternoon? Have you done it while polishing off a bottle of wine with the woman who will be mother of your children? WORTH IT

Rila Monastery – Bulgaria

What about taking an overnight Soviet-era train with your soon to be wife, mother, and brother from the beaches of the Black Sea to an ancient Orthodox monastery nestled among the spring acid-green of a Balkan beech forest?  Retiring to the old monks quarters after watching the Alpenglo fade from the Peaks? WORTH IT.

Waterfall in Iceland

Or, hiking back from a glacier-fed waterfall, eating roasted Icelandic lamb, and washing it down with a cool, crisp beer? WORTH IT

Or, remembering sitting next to a spring in the shade of a walnut orchard at 6,000 ft in the mountains of North Africa.  Relaxing there with your wife of 13 months while being served a three course meal of salad, mint tea, tagine, and fresh fruit that was packed over a mountain pass on a mule by your grouchy but affable Berber muleteer. WORTH IT.

Standing on the summit of the highest mountain in North Africa and the Arab world with her two days later? WORTH.  IT.

There are times in one’s life when you realize the window for a certain type of adventure is fading quickly.  Is it worth letting the window close because that money could get you a 7-8% ROI?  Life is complicated, messy, and that’s what makes it great.  I refuse to give that up in the pursuit of financial stability and gain.

Mindfulness and the FIRE Movement

what the financial independence movement misses

The FIRE (Financial Independence – Retire Early) movement is all the rage on the internet these days. Among physicians it seems especially popular with the younger crowd (<50 years old), though people of all stripes are interested.  I have been perusing many of the various blogs on the topic for months.  I have found something rather unsatisfying in the movement’s discourse. 

I want to make this clear: I am not opposed to financial independence or retiring early. It is a worthy goal.  I have used many of the discussions on financial discipline to improve my own financial position.  For instance, I now spend about 40% of my take home income paying down my student loan debt, which is the only debt I have.

I do not think people trying to FIRE are jerks, but I also don’t think the pursuit of FIRE is particularly mindful.  

Like so many things in life, the reality seems to be in middle. I do not believe that FIRE is inherently unmindful, yet I increasingly believe it can be slippery slope out of a mindful life.

In much of the discourse surrounding FIRE, the accumulation of money dominates the discussion, seemingly suffocating the reason for financial independence – a rich and rewarding life. 

Physician on FIRE seemed to touch on this in a post last year:

If I had discovered the FIRE movement as a medical student….I might have spent the last fifteen-plus years wishing life away. It would have been awfully tough to embark on a career with the express goal of finding my way out of it.  – Physician on FIRE

minduflness’ role

The basic tenet of living in mindfulness is living entirely in the present, as the present is the only moment that truly exists.  The opposite of “wishing life way.”

Much of the discussion about achieving Financial Independence seems to be of the “when I achieve FI, I will be happy because I will be able to X.” variety.  This is  textbook living in the future.

Being mindful doesn’t mean ignoring the future.  On the contrary, when planning for the future, being mindful requires being 100% present in the act.  But, spending 10-20 years of your life doing something you dislike just to have a future you like is NOT mindful.

You don’t have to wait ten years to experience this happiness. It is present in every moment of your daily life. – Thich Nhat Hanh

Addicted to delayed gratification

Doctors are really good at delayed gratification.  It is probably our primary coping strategy in life, especially early in our careers and training.  I can’t help but feel that a good number of physicians pursuing financial independence are falling back into the mindless trap of delayed gratification.

In particular, millennial physicians have arrived at the end of a long stretch of delayed gratification (training) and found the reward lacking.   Instead of doing the hard, soul searching work of learning to live in the present, I can’t help but see a retreat back into the protective shell of delayed gratification.

They put their nose back to the grindstone, hoping in vain that life will reward them afterwards.

Relegating grizzlies to Alaska is about like relegating happiness to heaven; one may never get there. – Aldo Leopold, A Sand County Almanac

I want to reiterate, I do not think think that people should life fiscally irresponsible lives and “treat themselves” with frivolous spending on things that don’t bring happiness.  The pursuit of financial independence builds multiple useful skills:  mental and behavioral discipline, learning to be happy with less, and long-term focus.

However, I do not feel the value of the skills comes from achieving financial independence.  Their value is only truly realized in the pursuit of a meaningful life.  A meaningful life is not easy, and happiness is not omnipresent therein.

We only have so much time and energy in our lives.  While I am in favor of sound financial decisions, avoiding debt, and maximizing savings, pursuing that goal to the exclusion of other aspects of life robs the present to give it to the future.   It is worth reiterating, we never actually get to live in the future.

Remember, even Moses never made it to the Promised Land.

FIRE isn’t good enough

My main beef with the FIRE movement is actually that simple.  FIRE is not enough. If the benefit of being financially independent is that you don’t feel enslaved to your job, that can be accomplished without having 25 times your yearly expenses saved. Unless, achieving financial independence is actually just about the money.

On the other hand, maybe others aren’t looking for anything more and I am the outlier.

“The greatest gift life has to offer is the opportunity to work hard at work worth doing.” – Theodore Roosevelt

Saying that being free to stop working at any time makes work better is like saying that being free to leave a marriage at any time makes the relationship better.  Maybe that is true, but as a married man, I don’t think that it is.

If you aren’t happy with the work you are doing, being free to quit isn’t going to make it better.  You’ll just stop doing it.  Finding work worth doing is the solution, not having more money saved.

In retrospect, I may have lucked out that I hadn’t reached Financial Independence when my daughter died and my partners treated me like shit. I probably would have just left Medicine entirely.

I still have not healed my wounds with Medicine. But I am being forced to try because I have not FIRE’d.  I am having to try to find happiness in the wilderness, instead of just wandering until I stumble.

I might have left Medicine an embittered, grieving former physician if I had had the chance.  Instead, I had to look around and forge a way forward.

In the end, Financial Independence should be the natural byproduct of a disciplined, well-lived life.  Achieving FIRE does not make your life disciplined and well-lived life.