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Walking the Ghost Road

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

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

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

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

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

Those Who Came Before

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

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

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

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

The Ghost Road

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

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

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

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

I reread the plaque explaining this grave.

A Life in a Paragraph

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

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

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

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

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

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

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

Doctors Get Sick, Too

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

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

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

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

Yet, We Are All Related.

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

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

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

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

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

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

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

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

Rugged Individualism Dies a Slow Death on the High Plains

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

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

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

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

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

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

Nonetheless, the Myth Lives On…

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

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

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

But Why the Rugged Individualist?

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

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

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

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

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

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

Treating the Chronically Ill Rugged Individualist

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

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

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

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

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

The Rugged Individualist often confuses stubbornness for strength.

An Encounter With a Chronically Ill Rugged Individualist

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

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

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

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

She barely acknowledges my presence “Go ahead.”

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

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

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

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

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

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

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

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

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

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

An Institution Funded through Enabling

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

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

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

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

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

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

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

The Costs of Healthcare Individualism

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

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

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

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

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.

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.

Back to Work

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

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

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

A Baby Brings Perspective

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

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

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

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

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

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

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

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

Good to be Back!

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

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

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

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

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

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

An Actual Emergency

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

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

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

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

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

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

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

“Oh, Shit,” I think to myself.

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

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

Getting to Work

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

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

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

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

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

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

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

The Thrill of Being Present

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

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

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

The High Fades

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

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

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

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

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

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

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

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

Are these even questions we can ask in American Healthcare?

Recognition

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

“Doctor HP,

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

Sincerely,

Your Medical Director”

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

Courage, Hope, and Other Faults

As you know, if you have read my story up to this point, my wife and I gave birth to a daughter who had congenital complications about 18 months ago. We ended up making the decision to take her home on hospice where she passed peacefully.

The last couple of years have been trying, to say the least. I have vivid memories from the days leading up to when we brought her home.

Courage doesn’t make you feel you better

My wife and I, as well as some of her extended family, were sitting around a table. We told them what we were planning to do. One of my wife’s uncles responded with a simple, “That is brave, so brave…” Tears welled in his eyes.

We had not thought of ourselves as brave. We were simply her parents, doing what she needed of us, even it hurt us deeply.

Being told we were brave, while very kind, was a poor salve for the wound we would nurse.

And so we rode through the mountains, with her on a portable ventilator, talking to her as we went. We watched her pulse oximeter drop with deceleration, her lungs unable to maintain with the additional pressure of her organs on her diaphragm.

So fragile was she born.

Yet, we have never second guessed and we do not regret. Such is life, we are promised nothing.

Hope can feel like a Fool’s Errand

Grief is a hell of a ride. The loss of our daughter, coupled with my disillusionment with medical practice, dealt me a double blow. I often found myself wondering what the point was.

Not the point in living, I was never suicidal – though I now have more empathy for those who get there. I do mean the point in trying.

After spending years pursuing a degree and training to help people, I found myself among the greediest, least introspective, and least honest people I have ever known. I doubted my own integrity simply because I had ended up among them.

And then, as my wife and I decided to start a family, we were gifted a gorgeous little daughter, who was not destined to remain with us.

The universe seemed out to teach me something, in the most painful way possible. Fate brutalized the two most significant parts of my life in short order.

Why try, then? Why hope?

We Don’t Have a Choice

Much like time, human beings must only move forward.

Hope, for my wife and I, was not simple. I quit my job. Luckily, this required a 90 day notification, so we were able to take some time to grieve. Then, we moved back to her home city. She got a job to secure health insurance and started working 1099 locums.

This was all done less than 6 months after our daughter died. It was a matter of survival. We were running on fumes.

Finally, after finishing our dash for survival, we had to truly face the future. We had to decide whether we had it in us to hope, to risk, and strive all over again.

And we did.

My wife recently gave birth to our second daughter. She is gloriously average. She is of normal weight, normal length, normal appetite, normal irritability. In a blissfully ignorant way, she is making stupidly adorable baby noises next to me as write this.

A Harrowing Gestation

As you might imagine, the nine months of this pregnancy have been gut wrenchingly anxious. The medical staff of a large research University, as a rule, made this worse.

Our new daughter did as well, by waiting a full 41 weeks before showing up – without an induction (though we had scheduled one).

We had so many instances of fear and hope and grief over the course of this pregnancy. While I plan on exploring these in more detail in future posts, it didn’t seem appropriate to do so before her birth.

“Our stories are not meant for everyone. Hearing them is a privilege, and we should always ask ourselves this before we share: “Who has earned the right to hear my story?” 

-Brene Brown

Both my wife and I felt that exploring these emotions prior to her birth on the blog was somehow not the right thing to do. It would have been inappropriately vulnerable.

The time for chronicling the complexity of awaiting the arrival of a child after loss was, for us, not until she had arrived safely.

And so we waited, and she is here, and we are happy, in a complicated way.

Shortly after my wife told me she was pregnant for the second time, we sat together in fear and grief and cried.

She looked at me and asked, “Why are we doing this? Why are we even trying?”

My heart broke. Of course, I felt the same way at times. I looked back at her and mustered a simple and resigned, “Because we are brave people and this is what we do.”

Are Population Health Initiatives Doomed to Fail?

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

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

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

Medicine

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

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

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

Healing has always been an individualized art.

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

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

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

Population Health

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

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

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

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

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

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

Nobody’s Business

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

-David A, Kindig MD, Phd

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

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

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

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

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

Responsibility without Power

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

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

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

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

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

That is not American healthcare.

Good Money After Bad

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

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

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

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

These are two totally different tasks.

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

The end result will be failing at both.

The Freedom Fallacy

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

– Willa Cather, My Antonia.

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

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

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

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

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

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

The Value of Work

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

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

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

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

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

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

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

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

Freedom vs. Fulfillment

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

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

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

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

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

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

Oh, So Many Red Herrings

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

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

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

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

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

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

Courage is not the Absence of Fear

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

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

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

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

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

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

Hemingway and the Danger of Persona

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

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

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

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

Personality vs Persona

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

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

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

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

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

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

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

Does the Doctor kill the Person?

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

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

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

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

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

“She was always so happy.”

“Everyone loved him.”

“She was so successful.”

Dissolving the Narrative Dissolves the Self

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

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

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

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

As usual, Hemingway says it best in his writing:

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

― Ernest Hemingway, Men Without Women

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

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

What is the Art of Medicine?

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” – William Osler

I have spent literally years of my life pouring over the “science of medicine.” I dedicated innumerable hours to memorizing biochemical pathways, pharmaceutical mechanisms, and equations for physiologic processes.

American Medicine assumes the science of medicine is the most important. We view it as an exceedingly important part of the training process. Yet, any physician will recognize the science only gets you so far.

Sadly, organized medicine dedicated much less of my formal training to learning the other part of medicine, the art. In medical school, the recommendation for learning the art of medicine was simply to watch someone who, in your opinion, was particularly good at it and emulate them.

Thanks, that’s helpful….

No one ever even defined what the art, in fact, was. Even now, when I search for a definition, a significant amount of variability in the definition floats around the internet.

Some say the art of medicine is the space in between the evidence and practice, the judgement we use when science cannot give us a clear answer. The art simply smoothes out the edges of the science in the real world.

On the other hand, others posit the art of medicine is the relationship, empathy, and emotional aspects of doctoring. It is the space we keep for humanity in the practice of medicine. The art of medicine is the properly placed hand on the knee, the right words said in comfort, the knowledge of the patient as a person beyond their disease.

I think both these definitions and all others that I have read sell the art short. They do not give the art its due place in the pantheon of our skills. Only recently have we began trying to teach medical students any skills which approximate the art of medicine.

What is Art, Anyway?

“Science and art,… they seek the truth and the meaning of life, they seek God, [and] the soul….” – Anton Chekhov

I don’t think we can truly answer the question of the what is the art of medicine until we actually understand the goal of art and the artist. Chekhov, who was both an artist and a physician, articulates the overlap of art and science well – seeking truth.

Science and art both quest for truth. Science seeks to understand the rules of the natural world so as to understand it, predict its outcomes, and hopefully influence them for our purposes.

Art, on the hand, seeks to create an entire world, the experiencing of which leads us closer to human truths. These are truths a scientific experiment cannot elucidate, because they exists only in human souls.

The human experience is often a reaction to the chaos of the world around us. Much of what plays havoc with our lives is beyond our control. Through art, humans create worlds where we mute the chaos, understand it, and give it meaning.

So, we will find the art of medicine in its truest form not in clinical judgement or in human actions, but in those moments where we the physician partner with patients to create new worlds in the pursuit of healing.

The Healing Art of Narrative

The essential task of the healing patient-physician relationship is the creation of a world where the destruction and chaos of illness is rendered understandable, and if possible, meaningful.

Which artform allows physicians and patients to create a world where healing is possible where only hours before there was only suffering? It is the art of narrative, of a story’s telling and untelling.

Make no mistake, the history is the first part of a patient encounter because it is the most important. The history, the patient’s narrative of the illness is what creates the backstory in which any healing must occur.

In the very moment when a patient tells you their story, they are creating the world in which their suffering exists and their healing must occur. Narrative must be heard to exist.

The act of hearing, of bearing witness, is just as integral the creation of the world as the telling. Notice the word bear/born in this context. Bearing witness midwives the world of the sufferer into existence.

The Use of Narrative

So, the patient has shared their story, you have born witness. The world has been created. As a clinician, you must accept the history. You can interpret it, but only for yourself.

If, as the clinician, you deny the truth of the history, you deny the existence of the patient and her story altogether. A person whose world has been denied cannot heal. We cannot “correct” the history. We must accept it and move forward in the pursuit of healing.

“A well-thought-out story doesn’t need to resemble real life. Life itself tries with all its might to resemble a well-crafted story.” 
― Isaac Babel

It is in these moments I believe a true practitioner of the physician’s art can shine. Through discussion, empathy, reframing, and a healing relationship the patient and the physician can together, begin to build a story about the illness, its affect on the patient and their world which opens the possibility for healing.

A New and Sudden Frailty

I am reminded of a man I saw in follow up for a hospital discharge after a heart attack, or MI. He was in his mid-sixties, generally healthy. No hypertension, no smoking, minimal lipid issues. The MI came out of nowhere.

The ED physician, cardiologist, and hospitalist had all done exemplary science. The physicians diagnosed quickly, treated appropriately, and discharged him with minimal loss of function. Nonetheless, he was in a stupor, rudderless.

Despite being grateful for all that his hospital team had done for him, he still felt less a person than he was before. He was struggling with the sudden transition from being a healthy, active, strong man to a man with a chronic disease. He went from no medicines to at least four daily pills.

As the physician, you must acknowledge the loss. What this man lost was his health innocence. He lost his ability to take his health for granted. He lost his ability to feel strong, vital.

And Now We Create

So, here is the exposed fulcrum of healing. You can imagine how this could go. He retreats into himself and begins to hide from activity that he worries could bring on another heart attack. He gains weight, starts to feel depressed, his relationship suffers.

At this point, he loses more than a small amount of heart muscle, he starts to lose life itself.

This would be possibly as devastating as the MI itself. For what is life without vitality? The deepest art of medicine lies in this moment, when together, we help this man build a new narrative for his life.

Hopefully, the narrative is one rooted in his past and which does not ignore the transition that has occurred but allows him to re-engage with the world as the richer person he now is.

Jan Steen – The Doctor’s Visit

This process is alchemical, because it depends on everything that is individual about the person. It is a tenuous moment.

It is a verbal and emotional dance that weaves the story of healing out of the tattered fibers of loss.

We as physicians in this moment must engage directly with this loss, its grief, and our patients’ human frailty and help them build a road out of the fear. Some people can do this on their own, but many cannot.

That, I argue, is the art of medicine. That is what an algorithm cannot predict and metrics cannot tell us. Not clinical judgement, or acronyms of empathy, but a truly engaged art of healing.