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A Birthday without the Birthday Girl

Wandering the Desert for A Year

landscape sand desert dune wind dry natural park outdoors dunes national shadows ripples grassland hot plateau habitat ecosystem sahara wadi death valley landform erg natural environment geographical feature aeolian landform

Death Valley Sand Dunes – Public Domain

The memories of a child lost so soon after birth are the definition of bittersweet.   A birthday is supposedly important, a time to celebrate.  Everyone else seems to think so.  People have sent us birthday cards, notes, texts, things to let us know they are thinking about us.  They are all very kind and sweet.

a day to remember

However, everyday for the last year has been a day of remembrance for my wife and I.  For her especially, there is someone palpably missing in the ether.  She feels it deeply, in a corporeal way.

In beginning, the world seemed a darker place.  Colors had less shine and everything was off kilter.  I notice those thing less nowadays.  Yet, I still haven’t decided if that means that things are brightening, or I am just forgetting what the world was like before our daughter left?

the sun came up today, like it usually does.

In the end, today is just another day without her for my wife and I.  The difference is that other people are thinking about her and her absence.  They are letting us know they remember.  Again, it is bittersweet.

The notes and cards and flowers are a helpful reminder that we are not alone in our grief.  Grief brings a sense of emotional solitude, so it is nice to have that reminder of others.

On the other hand, the notes are also reminders that my wife and I share a solitude in our grief.  We don’t get to take a day off.  We can’t choose to get off the grief train for a while and rest.  We are always there.  And, as far as we can tell, we aren’t going anywhere.

life in the hessian crucible of grief

Grief is a crucible.  The forces that it brings to bear on a person are immense.  Yet, crucibles are amazing tools for reshaping things.  Metals are melted, combined with strong reagents.  In the end something, hopefully stronger, emerges at the end of reaction.

Chemical reactions can go poorly.  Reagents in wrong amounts, too much heat, rapid changes in temperatures, etc.  These can force the reaction to go terribly, terribly wrong.  On the hand, the reaction can get stuck in a chemical purgatory.  The reaction has transmuted the initial components, but not delivered the final product.

The same is true for grief, it defines us for a time.  We must let melt into our identity, where it can combine with the pre-existing pieces of our being.  However, we must be careful.  If we hurry it, if we had too much pressure too soon, things can go very, very poorly.  If we ignore it, if we do not tend it, we can become moored in a netherworld.  There we may stay, beyond the reach of who we once were, but not delivered into we might have become.

to live a life in 3 weeks

Over the next three weeks, my wife and I will live through the entirety of our daughter’s life, one year removed.  It seems a strange twist of fate that it is an entire life.  Yet it is.  On a long enough time-line, 3 weeks and 90 years are indistinguishable.  They are equal in their measure – lifetimes.

And her presence was immense for someone who couldn’t even muster 5 pounds.  As measured by the emails, the cards, and the dozens of people who travelled from around the country to meet her during her brief time on this plane, she was mighty.

So, my wife and I enter the bittersweet season of her life.  Three weeks, forever marking October in our minds.  We walk along in her shadow, remember the beauty and the loss.  For you cannot have without the other.  Grief is the shadow that beauty and love cast when they are lost.  Yet, I would rather live in a world of shadows than one without light.

 

A Tale of Two Medicines

Bias in Medical Practice

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

tale one: rofecoxib

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

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

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

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

tale two: opiates

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

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

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

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

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

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

Rofecoxib and Opiates Kill People

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

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

to americans, addiction is a vice, not a disease

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

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

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

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

addiction is a terrible disease

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

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

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

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

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

 

An Introduction to Critical Access Hospital Doctoring Part 2

Doctoring on the High Lonesome

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

rural family medicine vs critical access medicine

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

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

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

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

swing bed programs

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

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

why can’t people just stay in the hospital?

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

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

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

swing bed can be a solution

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

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

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

trials and tribulations of a swing bed patient

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

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

critical access doctoring

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

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

An Introduction to Critical Access Hospital Doctoring – Part 1

Critical Access Hospitals (CAH)

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

how do you define rural?

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

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

okay, but what is a cah?

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

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

Why would a facility want this designation?

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

why pay to keep these facilities open?

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

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

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

But what about the doctoring?

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

 

Millennial Physicians Didn’t Start the Fire

millennial physicians

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

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

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

She wasn’t convinced that it was always necessary.

……

Do we have a millennial physician problem?

I’m not sure.

……

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

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

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

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

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

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

oh! the humanity!

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

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

the tribe vs the lone ranger

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

the h&P assumes a certain level of baseline health

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

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

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

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

THis tendency has been recognized before

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

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

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

 

 

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

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

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

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

-Samuel Shem, House of God
high plains doctoring

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

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

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

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

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

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

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

No.

Are interested in counseling?

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

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

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

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

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

good doctoring can be a drug

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

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

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

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

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

 

What Could We Have Done Better….Part 2

Life’s Hard-learned Lessons

“If people bring so much courage to this world the world has to kill them to break them, so of course it kills them. The world breaks every one and afterward many are strong at the broken places. But those that will not break it kills. It kills the very good and the very gentle and the very brave impartially. If you are none of these you can be sure it will kill you too but there will be no special hurry.”

-Ernest Hemingway, A Farewell to Arms

After reading my first post, if you did,  you probably felt the anger, and there is anger.  However, anger is not the only thing left.  I have found a lot of a lot of comfort in literature and art over the last year.  Art has the ability to make the very sad also very beautiful, which is at times  is all we have to hang onto as we wander through the wilderness of grief – the beauty of life.

And in those wanderings, you learn a great deal.  You learn about yourself, about your spouse, your family, your friends, and the world at large.  If approached in a certain way, it can be a great gift.  Do I wish my daughter could have lived independently?  Absolutely.  Do I wish I could go back to being the person I was before?  No.

I am so much more rich and human than I was before.  Yet, I have been broken by a double grief.  The grief for a life with a child that is not here, but also the grief for a medicine that supports and heals – both patients and their community of healers.  I am comminuted, displaced.

By Bill Rhodes from Asheville – mid-shaft humeral compound comminuted fx lat, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=5784840

My anger is actually not all that personal.  I certainly would not count my former partners as friends, or even colleagues.  I have come to understand how deeply medical training unmakes and then remakes a person.  After 4 years of premed, 4 years of medical school, and 3-5 of residency with possible fellowships thereafter, you have been destroyed and remade in the image of Medicine.

It is often not for the best.  I do not think my former partners or administration were particularly good people, nor do I think they were particularly bad people.  I think they were products of the system, which it takes amazing strength and courage to fight day in and day out.  The system never rests, doesn’t take breaks.  It has no humanity.  Who is strong enough to confront that?

And there is the problem, if I just thought that I fell in with a bad group of people, then I could just find another practice and feel like everything would be okay.  However, increasingly, I think that what I experienced is the natural outgrowth of our current Culture of Medicine.  Over at the Happy MD he refers to it, in part, as the “Lone Ranger on a Gerbil Wheel Syndrome.” How can you save anyone else if you are drowning yourself?

Now, I find myself a nomad doctor on the High Plains, too wounded to try and commit to another organization, community, or practice.  Seeing patients I can do, but I have to use shiftwork to protect myself.  I am too vulnerable, I had grown to love primary care and find purpose in healing.  I cannot take another heartbreak right now.  With time, I may become strong again at the broken places, but the callous around the bone is fresh.

I am still “non-weightbearing.”

What Could We Have Done Better….Part 1

Everything that comes after in this blog will be informed by this experience.  So, I feel that I have to start with it.

Scene: My last medstaff meeting in my previous job after making my resignation official:

One of my partners: Can you elaborate on why you are leaving and what we could have done better to help keep you?

Me:  I have found that emotional intelligence is not valued here.  I feel less human because of the year I have spent here.

Same Partner: That is very sad.

Other partner: Can you elaborate on what you mean by that?

Me(tears starting to form):  Not right now.

Later that day I was told by our clinic manager that all of the medical staff told him that they had no idea I felt that way.  I felt my point about emotional intelligence proven.

Stepping back a few months…

I had been in this practice for almost a year and we were expecting a new baby.  Because of how tight the call schedule was, I had only opted to take the 2 weeks off around the suspected due date.  I had repeatedly asked the administration and my partners to arrange for back up coverage because things often do not go according to plan with babies.  Things did not go according to plan.  My wife was induced at 37 weeks (3 weeks early) for polyhydramnios.  Our beautiful little girl was born and required significant resuscitation, ending up in the NICU on a ventilator with a feeding tube.  I called and told my partners not to expect me back until further notice.

The news didn’t get better.  She failed extubation twice, she didn’t have the strength to swallow or breath without mechanical support. We never got a diagnosis, which wasn’t surprising or upsetting.  Diagnoses rarely help patients as much as they do doctors.  A rose by any other name would still require ventilator support.

We started hospice/end of life discussions with our neonatologist.  That same week my partners called to see if I could cover call on a Saturday because “no one else was available.”  Not like I had anything better to do….(I refused).

We took her home on hospice.  She was extubated on our front deck in the sun and she passed peacefully.  It was beautiful, and terribly, heart-wrenchingly sad.  She was three weeks old.  We cried, a lot – we still do.  We a took a week and scattered her ashes on a sacred mountain.

Rachel Weeping
Photo Credit: By Charles Willson Peale – Philadelphia Museum of Art, Public Domain, https://commons.wikimedia.org/w/index.php?curid=7365050

I decided I should ease back into work.  It had only been 4 weeks since she was born, less than 2 since she passed.  It was probably too soon, but I figured that I would have to sooner or later and easing in would be best.  No one gives you a guidebook for navigating the death of your newborn child.

I felt that I had communicated that I wanted to ease back into work.  My partners felt that it was appropriate for me to take back on my full call burden.

This included the following: 120 hours of ED call within 7 days including Thanksgiving.  The 72 hours of call before 8 AM on Christmas morning, and the 24 hours following Christmas. I was still the f***ing new guy, apparently it didn’t matter that I had lost a baby with whom my wife and I were supposed to spending our first holiday season, but weren’t.

When I tried to back off and protect myself, here is a greatest hits of things I heard:

—–

After effectively being told that it would be too difficult to find someone else to take my call:

Me:  You know, I still have over 30 days of paternity leave I could take.  I don’t have to be here, I came back to help.

Partner:  Well, it would have been easier to arrange coverage if we could have planned for it.

——

CEO in one conversation: We want to support you however we can, but the other docs are already run pretty ragged right now.

CEO in another conversation: We may not always do the right thing, but our hearts are in the right place.

——

Same partner as above in a conversation about me possibly switching to do just hospitalist/ED work for a time: I would hope that you think about the burden it would put on us to cover the outpatient work if you were to do that.

what could we have done better to help keep you?

I guess you could have just been the human beings and caregivers you say that you are….