In My Humble Opinion

I Should Have

2013-05-25T13:09:00.001-07:00

There's something strangely heart breaking in the You Should'ves:

You should've treated the infection sooner!
You should've made the diagnosis faster!
You should've done more!

These words uttered accusingly from a patient's mouth can cut to the core of a physician. We've all been there. No matter how rigorous your skills and training, there will be many bad outcomes. Unfortunately, from time to time, a patient or family will point the finger directly at you.

I don't blame them. How else to deal with death, destruction, and illness. Some turn inward. Some point to the heavens and ask why. And some look you in the eye and spit venom in your direction.

I always try to step back and appraise the situation as objectively as possible. I am not infallible. Humans make human mistakes. But often, I find, that bad things happen without adequate explanation. We are both wondrous machines with infinite intricacy and ticking time bombs all at the same time. If I thought accepting the burden of blame would ease the suffering, I would throw myself under the bus without question.

We all know this won't undue that which has already been done.

Yet, there is a menace, even more devastating to the psyche of those who have taken such sacred oaths. I am referring to none other then the havoc wreaked by the I should'ves. Every physician I know is haunted by the times when their skill fell just a little short, their insight was lacking, or their timing was imperfect.

These are the cases that make you toss and turn through sleepless nights. These are the faces you carry year after year.

So you walk into the room of the grieving patient or family. You look these people who love and trust you in the eye, and you tell them of your shortcomings. Mostly they shake their heads and forgive you quickly. It's of little consequence that you shamefully accept the comfort they bestow on you. You will not escape unscathed.

Over the coming months and years,

the wounds you inflict on yourself will do nothing but fester.

In Memoriam: Letting People In

2013-05-21T18:21:00.001-07:00

They found you in death much as you had been in life.

Alone.

You once told my office manager that I saved you. I shrugged. I couldn't help but feel that I was watching you die day by day. It's not that I didn't try. I fought with you tooth and nail. Begged you to go to the hospital, for anything: a pneumonia, vomiting, I would have been willing to make up a diagnosis. But you told me that hospitals were places that people go to die.

I watched and waited. I scolded that one day I would get a call from the police telling me you were gone. You lived up to that prophecy. I wondered back then how I would feel. I suspected some version of relief. After struggling for months and years, I couldn't help but suffer a certain amount of battle fatigue. I now know more accurately what resides in my heart

Emptiness.

Something strange happens when people let you into their lives. You struggle through their peaks and valleys. You become soldiers in a common battle. In many ways they become a little part of you. The hazard in this profession is letting too many people in.

Because they all die eventually.

And tragically, predictably, a special piece of you goes with them.

Embrace The Joy

2013-05-18T17:11:00.000-07:00

It's not exactly Dr. Jekyll and Mr. Hyde, but everybody knows my level of patience varies from time to time. So I was surprised to find myself happily telling the emergency room that I would assess the patient shortly. The kids were horsing around on the playground, and I knew I would have to call my wife and ask her to come home. It would be my second forty five minute trip to the hospital on an otherwise busy Saturday afternoon.

For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, listened to the patient calmly, and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn't my life's work make me feel this way all the time?

I guess it starts with one simple fact. I blame myself: every heart attack, stroke, or new diagnosis of advanced cancer. As disturbing as it sounds, how could I not? It takes a certain type of personality to want to be a doctor. A kind of hyper conscientiousness pervades our wounded souls. What else would drive us to study while our cohorts play, or slave away in gross anatomy while our peers receive their first pay checks? And how does one wake up in residency after an hour of sleep with a foreboding sense of nausea and fatigue, and face an overwhelming twelve hour day of patient care?

You learn to believe that your actions matter, that your struggles draw the line between life and death. If you only work harder, stay up later, study more, bad things will cease to happen. This is the promise that drives us through these PTSD inducing situations. And, of course, the joy.

The joy in those fleeting moments where you hold a hand, sigh gently, and become one with the great swath of murky humanity. Those moments are what sustains us through the everyday torture that many of us signed up for eons in advance of the knowledge of what we would be doing.

Half of today's practicing physicians have been irreparably damaged by the experience, and huddle behind walls so impenetrable that patients can't break through their stone faced facade. The other half are trying so desperately to once again feel deeply, and yet not suffocate under the immense pressure of their daily lives.

If your are a patient, I suggest you avoid the former and seek out the latter.

If you are a medical student, you may want to learn how to embrace the joy now,

before it's too late.

In Which I Respond To A Faithful Reader

2013-05-16T08:22:00.000-07:00

Below find excerpts of an email sent by a faithful reader. I have included the whole text, but broken it down to respond to each point accordingly.

I have really enjoyed your blog postings and the sensitivity you showed toward patients. But, your new venture is a real turn off, and makes it hard for me to want to read your posts anymore.

I have been waiting for this. Expecting it. I knew that when I changed my practice model there would be anger and disappointment. For this reason, I have gone to the trouble of telling each patient face to face in the office when they come in for an appointment.

This has been my decision. I will own up to it. I won't hide behind a formal letter or slink out of the room. If patients are upset, I will soak in the anger and accept it. I owe that much.

So far I have received mostly understanding with a smattering of joy and disappointment. My patients know me very well, they don't believe I mean them harm.

My dear reader, sometimes you have to look eye to eye to see into some one's soul. A blog, unfortunately, does not allow for that.

As a patient (not yours), it seems like you are abandoning patients who do not have the money to pay your new fees for which you will take no insurance. Instead of staying in the trenches and finding the insurance battle with them, you seem to be washing your hands of it and leaving them on their own. Onward to people with disposable incomes to pay for handholding.

On the contrary, I'm still taking insurance. For fifty percent of my practice: nursing home, hospice, and palliative care there will be no extra charge. These are some of the most difficult and high risk patients. I will continue to stay in the trenches and battle for them.

I am changing, however, my outpatient primary care practice. I will charge a yearly fee along with billing insurance. The yearly fee pays for uncovered services like home care, cell phone access, and prolonged visits. I believe this is a fair trade off.

My perception may well be wrong. Perhaps I did not listen carefully enough to your explanations. I want to believe that you are who you appeared to be, a great, caring physician. But, I thought that you might like to know that at least one of your loyal blog followers doubts that now. Take care.

I would like to think that I am still perceived as a great, caring physician. I would also hope to be viewed as a strong patient advocate. But the problem is, I can't protect my patients from the ridiculous, pervasive stupidity of medicare and our modern day insurance Goliath.

I can keep bending, and giving, and finding ways to work around the vicious beast. Or, I can choose to step out of the lion's den. I will not be an enabler of this broken system.

Change will only come when doctors and patients alike are willing to stand up and say enough is enough.

I am in the unique position to do just that.

Practicing At The Top Of Your License

2013-05-14T19:48:00.000-07:00

My son and daughter play violin. I accompany them to every class and stand over them in our living room as they practice. From the very beginning, the teachers required parental involvement. They often spent more time talking to me than my children. They instructed on posture and fingering. Eventually, I learned to read music. I even rented a violin of my own.

As the years have passed, I still play an active role. I know when my son's elbow rides too high or my daughter's wrist curves upward like when carrying a pizza. My ear can tell when a note is a touch too sharp or completely wrong. But as an adult, I find I have little time to practice the same hours as my offspring.

I returned the rented violin after months because it sat unused in the corner.

My children have far surpassed my abilities. Although I have knowledge of the appropriate technique and have learned the series of notes, I am a victim of insufficient practice. And indeed, one can look down the line from less to more experienced and realize the difference repetition makes. Although the notes are the same, the depth and quality of the sound that reverberates through the violin can be very different.

Only when one practices hour after hour, year after year, can the shadowy mirage of mastery shimmer in the distance.

There are no shortcuts.

Not in violin,

and not in medicine.

Caring 2.0: #HCSM And The Rise Of The Empathic Physician

2013-05-13T18:29:00.000-07:00

We have our rock stars. Our members in the healthcare social media realm who have elevated the conversation to new heights. Physicians are tweeting, blogging, and popping up on news shows across the country. We are using our singular voices to educate on vaccines, heart disease, and the quantified self movement. We are acting locally, but teaching globally. The promise of social media has amplified our voices and carried our message to the unwashed masses.

We once could affect the few thousand who passed through our office doors. We now can touch the lives of millions. This dichotomy, fulfilling our individual covenants as well as our debt to society as a whole, has proven a powerful draw. One only has to look at the conversations on twitter to realize that our ranks are swelling. Not only physicians, but nurses, pharmacists, patients and advocates are both teaching and learning.

We all win, patients and providers alike.

Yet in our exuberance to transform, we continue to neglect certain self evident truths. It's time to pivot. It's time to not only tell people what we know, but who we are. Knowledge has it's limits, but does caring?

I propose we move to a Caring 2.0 mindset. The days of unidirectional emotion emanating from patient and bouncing off stoic expressionless physician are gone. Like the Healthcare 2.0 movement, the elevation of caregiving requires a blurring of the line between teacher and student. I can see no better way forward than social media.

We are human. We suffer, triumph, and struggle with our own inner demons. As Louise Aronson said in her book A History of the Present Illness:

Doctors, you see, aren't so different from patients. Every day we hope someone will see past our elaborate and very impressive window display to the jumble of expired products weighing down the shelves and choking the aisles of our psyches.

It is in this imperfection that we realize our best version of ourselves,

that we become the doctors our patients really need.

CrisisMD Launched Today

2013-05-10T09:24:00.000-07:00

CrisisMD.com launched today!

Our goal is to provide healthcare coaching, translational services, and advocacy to those in the midst of a crisis. Below find the post that spurred this business venture. It appeared recently on kevinmd.com.

If Only The Patient Had An Advocate

It had all been so easy when Jim was still around. Lisa’s ex-husband had many shortcomings, but being a critical care specialist sure came in handy. Any time her mom or dad had a health crisis, he was right there in the middle of it: advocating, interpreting, breaking down the complexities into easily digestible morsels of information. But then Lisa’s father died, and the emotional and physical stress brought the unstable union to a breaking point.

Years later, she sat in the ICU holding her mother’s hand and longing for the man that she had grown to despise. She felt a slight tenderness stir in her heart that was suddenly extinguished by picturing her previous husband with his new, almost teenage love interest.

Damn!

Lisa’s mother suffered another stroke. The ventilator had been removed but her mental state was dubious at best. She was not eating. And the hospitalist was suggesting a feeding tube. Lisa recoiled. Her memories of her agitated grandmother socked away in a nursing home pulling on the plastic protruding from her abdomen was too much a burden to be replayed a generation later.

If only Dr. Phillips would come to the hospital. As her mom’s primary care physician, Lisa trusted him. But he abandoned his privileges years ago. He once confided that he no longer knew how to take care of such sick patients. Lisa missed his optimism and his gentle hand on her shoulder resting tenderly. He understood her struggles. The hospitalist was nice enough, but young. He seemed overly concerned with protocol and rarely spent more than a minute in the room without leaving to answer a page. He certainly had no advanced knowledge of the woman lying in the bed in front of him.

The family meeting was pathetic. Instead of the hospitalist, a palliative care nurse joined the social worker and other supportive staff. Thirty minutes later, Lisa walked out more confused than ever. Most of the conversation resolved around disposition: nursing home, home with hospice, or rehabilitation center. Each member had their own checklist of salient decisions that often seemed far removed from her mother’s wants or needs. There was no question who each participant worked for. The hospital, the government, anyone except for the poor helpless struggling patient.

Lisa thought of Jim again. If only she had an advocate. Someone who answered to her and her mother instead of the litany of outside interested parties. If only her doctors would lift their heads from the computer screen for just a few moments. If only someone with medical knowledge took a moment to see the forest from the trees.

The mice keep running through the maze trying to find the elusive cheese.

Damn!

What the hell has happened to our medical system?

Poof!

2013-05-09T11:37:00.001-07:00

It happened once before. I logged onto the computer on a particularly challenging day to find that my blog was gone. Just like that. After countless posts, telling stories, complaining and rejoicing...poof. I was on WordPress at the time. I called the help line and frantically explained the situation. Weeks later I got the data back, unformatted and imported to a new web address.

I was crushed. Not just about the loss of all that writing, but more because the conversation had stopped. The unidirectional talk that I had been having with myself and my readers came to a sudden unexpected end. And when it finally came back, the connection had severed.

For a long time there was silence.

My writing is now hosted on blogger. Four hundred and seventy six posts later, the self expression dwarfs that of it's forebearer. Yet, I have taken no actions to record or backup my posts. Like a game of Russian Roulette, I keep hitting the publish button in complete denial. I have no explanation why I am paralyzed in taking such precautionary measures.

Poof!

Many have told me to collate my posts into a book. They say to self publish or get an agent. I have contemplated many times. But I could no more anthologize than I could backup my blog. We don't record our conversations with our friends, our loved ones. We remember them.

And this, my friend, is my conversation with you. I spew forth the randomness and you sometimes respond. You comment, email, or retweet. We have a relationship, real or imagined, I can't always tell.

I guess it was never really about the specific words.

I was just trying to tell you things.

Fatherhood And My Son's Kindle

2013-05-07T12:49:00.002-07:00

It's kinda curious. For all the technology I live and breath, put me in an empty room with an IPAD and after a few minutes of browsing, I'm bored. I've tried to wile away the hours on the Internet, but I can't. I'm just not built that way. Even the games and downloads lose me fairly quickly.

My son, on the other hand, is an altogether different creature. He somehow wrangled us into allowing him to use his own (birthday) money to buy a Kindle. And at the age of eight, he is already bumping heads with his fifteen minute daily allotment. He carries the little device in it's dark blue case around the house like a trophy. He may be limited in minutes, but no one can deny him the pleasure of feeling the weight underneath his wanting hands.

For him, the tiny screen frames a world of wonder and technology. It's not just the games, but Google Earth, Wikipedia, and a vast marketplace for all those lovely objects his rambuctious boy mind desires. It's a destination unto itself filled with both learning and shiny sparkling objects.

It is what his heart desires above all else.

He takes the Kindle everywhere. He lugs it to the grocery store, paws it at Home Depot, and cradles it before violin practice. It's always by his side.

The other night after a long shopping trip, we gathered the kids together for an evening bath. My son ran into the room frantic.

Mommy, Daddy...where's my Kindle?

An exhaustive search of the house lead to a startling conclusion. We must've left it in the shopping cart at Target. My son twisted his hands in knots waiting for me to connect to the lost and found. Nothing!

As I lay awake that night, I listened to him toss and turn in the adjacent room. Occasionally he would jump out of bed and search an odd drawer or basket. The next morning he crawled into bed between my wife and I. His eyes full of tears, he nestled into my arms.

As silly as it sounds, I hurt for him. I hurt for his little boy hopes and dreams. I mourned for the exquisite suppleness of inexperience. Of course I could buy him another kindle (which would have taught him nothing), but I can't protect him from the hardships of growing up. I couldn't protect myself.

There will be fights, both physical and mental. There will be disappointments and broken promises. There will be somatic and emotional pain. And like the heart extirpated wildly from my chest, I will have little control over his destiny, yet will feel each horrible prick.

I am like my son, and he is like my Kindle.

I am starting to lose him already.

The Power Of The Pen?

2013-05-04T18:54:00.001-07:00

I almost fell off my chair. It was bad enough that he showed up to the ER. But what happened next really blew my mind. He fell and bruised a rib. The pain in his left chest had obvious enough origins. But triage had put in for an electrocardiogram and the interpretation apparently scared the resident. The attending took a look, and shook his head.

Left bundle branch block. Better call the Mecca.

A few minutes later a cardiologist and nurse manager were videoconferencing in and interviewing the patient. Next came an order for thrombolytics and transfer to the big medical center ninety minutes away by ambulance (the same medical center that owned the emergency department as well as the local hospital the ambulance bypassed).

Rules are rules. And the bylaws state that all patients given thrombolytics have to be transferred to the brand new multi billion dollar cardiovascular institute no matter how far a distance. It didn't hurt that said institute was having trouble filling it's beds and apparently the administrative folks were starting to lean on the clinical staff.

The cardiac cath was mostly clean. Was it an over call, or did the medicine really just do a great job? He was never given a clear answer. He left the hospital with more questions then answers, and a prescription for a baby aspirin and a statin. He came to my office to try to figure out what had just happened to him.

This sort of thing seems to be occurring more and more often. The business aspects of medicine are starting to trump appropriate care. While no one is saying that more is better, aggressive management has become the rule and not the exception.

Healthcare reformers, politicians, and policy wonks wag their fingers at physicians and place the blame squarely on our shoulders. They say that only the doctor has the power of the pen. They completely ignore the bullying, administrative pressure, and the automatic rules and regulations forced on clinicians by the nonclinical (or no longer clinical) C-Suite.

A recent article in The American Medical News brings to light a radically different view point.

When the federal government sorted through the first round of clinical information it was using to reward hospitals for providing higher-quality care in December 2012, the No. 1 hospital on the list was physician-owned Treasure Valley Hospital in Boise, Idaho. Nine of the top 10 performing hospitals were physician-owned, as were 48 of the top 100.

This news comes three years after the Affordable Care Act effectively prohibited the expansion of such existing facilities and severely limited the creation of new ones.

As Obamacare pushes more and more physicians out of decision making positions and herds them into large academic and nonacademic hospital systems, one would expect one thing and one thing only: spiraling costs. Business exists in order to make money. Businessman go to school to learn about profit. Physicians who leave clinical practice to become administrators aspire to similar ends.

Physicians are the only ones who have made a covenant. We are the only ones who have taken an oath. We are smart, well educated, and innovative. And we have to look each and every patient in the eye before making decisions.

Yet time and time again, we are asked to move out of the way so the smart guys with the business degrees can come in, and make the tough decisions.

(Disclaimer. This story is an amalgam of a number of experiences gleaned over years of practice in a number of different hospital systems. The details of the actual medical story are fiction. Neither the patient mentioned or the medical center are meant to be reflective of any specific patient or hospital.)

An Act Of Submission

2013-04-30T13:46:00.000-07:00

As I reached for the doorknob with my right hand, I had but one and only one impulse.

Run! Turn around and run as fast as you can!

It's fair to say that being a physician requires a certain constitution. When one deals in the currency of death, it becomes second nature to hold our heads high when others fall. How else can we view the tortured realities of existence. The average life is chocked full of suffering. People die tragically, unexpectedly. Pain rips through the tender belly of humanity leaving us raw, and yet we stand our ground.

But sometimes it's different. Sometimes the guarded armour of the physician is pierced in just the right fashion to expose the glistening skin overlying the Achilles tendon. We fall, mortally wounded but unable to close our eyes. It is in these times we learn to hurt all over again.

It is in these times, you either shield yourself, or open the door and let the pain run right through you.

I choose to open the door.

The act of writing about what hurts usually soothes me. It gives a morsel of control over that which is ultimately ephemeral.

Today, writing it is an act of submission.

As the raging waves of the ocean crash against the shores of my insides, the waters eventually calm and the tide recedes.

And I am empty once again

Do You Know?

2013-04-26T18:57:00.001-07:00

Do you know?

I realize how I must sound. Throwing around the word futility like a game of dominoes, I slam the last piece onto the table defiantly. You glare.

She's not your mother!

I want to shake you. Of course she is. They are all my mothers, sisters, and brothers. My father who died when I was ten and my grandmother who waited for me to drive from St. Louis before drawing her last breath.

I won't escape unscathed. My birthright is to experience the allotted measure of human grief. But I'll lose your mother too, and thousands more. Sadness will be my daily companion, collateral damage from the oath I so naively took all those years ago.

Sometimes I sit in bed after being awoken by your mother's nurse. I stare at the ceiling and listen to the walls exhale deeply. I dream that when I die the spirits of my deceased patients will come to greet me. A parade of old and young, angelic and bruised. They shake their hands over their heads, and I can't discern whether they are clenching their fists in anger, or signalling affably.

I know, for better or worse, the consequences of my actions.

Do you?

Do you know?

Jordan Grumet Interviews Himself, Again

2013-04-25T12:16:00.001-07:00

I caught up with Jordan Grumet, physician, Internet entrepreneur, writer, and overall man of mystery in a secluded corner of Panera Bread Company.

Q: Jordan, this is the third in a series of self interviews over the last two years for this blog. Tell me, is anyone else (present company excluded), interested in what your doing?

A: Actually, my life story was recently presented to a distinguished group just last week.

Q: And how was it received?

A: My son's second grade teacher said he did a really stellar job!

Q: Um...OK. You recently were featured in Mike Sevilla's Family Medicine Rock's online radio show. How did it feel to be interviewed by a social media legend? And tell us about your new practice.

A: Mike is the real thing. His voice, his interview skills, it's like being on Oprah (I know you're out there O. You haven't returned my calls yet!)

I'm really excited about the upcoming changes. As of January 2014, I will no longer be seeing patients in the office. Instead, for a about a tenth of my current population (250), I'll be doing comprehensive primary care from the comfort of their own home. I'll charge members a yearly fee to allow myself to break the economic bonds forced by Medicare.

Q: What prompted you to make the change?

A: Medicare, healthcare reform, medicare, medicare, and healthcare reform

Q: Explain?

A: The delusional administrative and regulatory requirements by our governmental agencies are hampering basic medical care. We our losing sight of our patients, and spending time and energy bowing to the electronic dictates of an insatiable monster.

Becoming a master diagnostician is an ideal that takes a hundred percent commitment. Every click, form, and ridiculous constraint takes our eye off the ball.

By collecting the funds required to support myself completely outside the system, I will for once be free. Medicare can do what it wants.

C'est la vie!

Q: Is it true, that you are also starting an Internet business? CrisisMD.com?

A: Yes. What I enjoy most about being a physician is helping people make complex decisions. As most of us know, our healthcare system has been so perverted that we can no longer count on our own personal doctor to guide us through medical care. What with meaningful use, HIPAA, and completing yet another idiotic MOC (maintainence of certification requirement by the ABIM), who has time to spend hours with patients and their families making complex decisions?

CrisisMD does! We provide healthcare coaching, advocacy, and interpretation. We are not your doctor. We don't diagnose, examine, or treat. We translate.

Make no mistake. When you arrive at the doctor's office or the hospital, you are entering a foreign land. The language may sound familiar, but it's not what you speak at home!

Q: Wow! With all these balls up in the air, how do you have time to sleep?

(A crash is heard, Jordan has dozed off and fallen forward into his lukewarm bowl of broccoli cheddar soup).

Q: That's a wrap. Somebody get this poor slob a towel and clean him up.

An Open Letter To @kevinmd

2013-04-24T05:38:00.000-07:00

I think this needs to be said.

I have been writing a long time. I have been blogging since 2005. In all this time, I've learned much about social media.

There is a problem with content. No matter how important it is, and how good you are at creating it, it all means nothing if you can't find your readers.

Content comes first, then amplification.

There are many amplifiers out there: Twitter, Facebook, etc. I have tried, succeeded, and failed at using many of them. But by far, the most effective amplifier in the health care social media world is Kevin Pho and his awe inspiring website kevinmd.com.

I have been reading Kevin since my earliest dipping of toes in Internet based self expression. I have watched his site morph from a personal blog to an open forum for today's opinion leaders to express their latest insights. Never, I repeat never, has the information been stale or dated.

Over the years, I have been lucky enough to have Kevin pick up and publish a number of my blog posts. The opportunities afforded me through his attention have lead to media interviews, publications in major periodicals, and invitations to speak in exotic places (and get paid for it).

As his website proclaims, he truly is "Social media's leading physician voice". He also appears to be a kind, down to earth, stand up sort of guy.

Kevin, you have paved the way for many of us in the heath care social media universe. You continue to deliver day after day, year after year.

From the bottom of my heart,

Thank You!

CrisisMD Launches Soon: Guidance Through Uncertainty

2013-04-22T06:31:00.000-07:00

When was the last time you were in a medical crisis?

When was the last time you had a health scare with a family member and felt you had no one to turn to?

The medical landscape is changing. Healthcare reform, economics, and the modern agrahospital system are clouding basic personal care. We no longer treat patients, we treat communities. We no longer heal our patients, we manage their insurance companies, input their data into impersonal computer systems, and spit them out of the hospital with a nonsensical set of discharge instructions. The doctor who performs your yearly physical is different from the doctor who triages you during an unplanned office visit or who oversees your hospital care.

Frankly, it's not surprising that patients and families with no medical training or experience are floundering under the weight of this awkward system. How could you not?

I proudly announce the upcoming launch of CrisisMD.

Visiting the hospital or doctor's office can feel like entering another country. The terminology is unfamiliar and the process convoluted. CrisisMD will help fill the gap. We provide healthcare coaching, advocacy, and translational services to families in need.

Please support this venture by:

Following on twitter: @CrisisMD
Liking on Facebook: https://www.facebook.com/CrisisMD
Or visiting our website that will launch in the next few weeks: www.crisismd.com

Show Time

2013-04-20T19:23:00.000-07:00

My daughter is surrounded by a gaggle of small girls. Half the cohort marches forward gingerly on their skates while others have learned to glide. It is the first act of a two hour ice show at the local rink. The little ones have been practicing every week for the last few months. This is their first attempt at performance.

As the show progresses, the age and the skill set of the skaters improves. Those of us in the crowd can tell fairly quickly the talent of the soloists. Some have the God given grace and bearing of performance, even though they have not yet mastered the intricate movements. Others hit the jumps cleanly, but somehow struggle with the appropriate posture.

Then, then there are the ones who have it all. We hold our breath as they speed by and effortlessly nail a series of complex moves. It's almost easy to forget that years of practice have lead to this moment. While their friends were clowning around on the weekend, these teens were in the rink sweating: before school, after school, on holidays.

As my daughter waddles off the ice to the rousing applause of the audience, I wonder what her future will hold. The same goes for my son and the violin. Will these be just passing fancies or something more?

It certainly never happened for me.

Growing up, there were no sports I excelled at, no instruments that bent nimbly under my fingers. And I regret it. I regret not becoming a gymnast or concert pianist.

But I wouldn't say I wasted my youth.

I was in the library. Locked in my bedroom, I poured over school books hour after hour. knowing I wanted to be a doctor since preschool didn't make the subjects any easier. I struggled.

While my friends in high school were cruising chicks at Northbrook Court, I was buried in algebra. I spent countless Saturday mornings in the law library while the rest of my dorm was getting drunk at the football stadium.

I remember each test, each landmark: the SATs, The MCATS, Step 1, Step 2, Step 3, and the Internal Medicine boards. How many little moments go into artistry? I stumbled through the first patient encounter. I tripped over diagnosis after diagnosis. One day I was a resident, the next a full fledged attending.

Although what I do may not always be pretty, I perform each and every office visit. This is my art.

This my triple axle.

Sometimes I nail it. Others, I fall on my rear.

Take away the computers and the annoying paperwork, it's just me and the patient sitting in the exam room.

I prepare my instrument and flex my calf muscles.

It's show time.

Jumping The Fence

2013-04-18T18:40:00.000-07:00

It would be an understatement to say that things have been a little topsy-turvy.

I tossed and turned last night as the thunder cracked and sheets of rain slapped against the windowsill. My body rose out of bed by habit, minutes before the alarm released it's throaty bellow. I hunkered into my spring jacket and ducked out the door, through the backyard, and into the garage. The drips of water fell off my brow as I climbed into the car.

Visibility was poor. The entrance ramp was under a few inches of water, and my car lurched forward slowly. Thankfully, the highway was clear. Miles down the road and picking up speed, I saw the familiar line of break lights in the distance. I slowed down cautiously before coming to a complete stop. I was stuck.

At the end of a long line of cars with an impenetrable swamp obstructing my passage to the hospital, my options were sparse. I felt a sinking sense of doom. Like a caged bull, I could butt my head against the bumper in front of me, but it would be an act of self flagellation. There were patients waiting, but I couldn't get to them.

I craned my head in desperation, complete darkness. Not a single vehicle on the road barreling toward me. So I whipped into reverse, clicked on the blinkers, and drove the wrong way down the shoulder till I could exit off an entrance ramp.

Driving the wrong direction on the expressway is an odd feeling. It's like being given special glasses to look directly at the sun. Your mind can rationalize the action your body is initiating even as the muscles fight to maintain the status quo.

But at some point, you take the path that is given to you.

Many of us bulls are waiting till the door of the pen is flung open, and will run as directed into the arms of healthcare reform.

I, for one, have chosen to jump the fence.

And gallop the other way.

Aftermath

2013-04-16T18:03:00.000-07:00

I have watched people die. I have pounded on the chest of a teenager as the cerebrospinal fluid seeped out of his ears after being swiped by a truck on Lake Shore Drive. I have told parents their child has died and children their parents. I have stood at my father's grave before the end of my first decade.

There is no light in premature death, no beauty, no joy, no optimism.

Yet, there is solace in this wondrous profession. I have opened my mouth to the great fire hose to have a small taste, even as the whiplash strained my neck. I am scarred and worn.

The only salve to heal these wounds is the opportunity to stem the tide of this all consuming blackness, to soften the blow.

What lies in the great divide between love and pain is basic humanity. When religion, fundamentalism, or mental illness drags ideology outside this continuum, it is easy to lose faith.

It is becoming difficult to explain to my eight year old son why we are doing such a lousy job of protecting his peers. And admittedly, I don't know how to find a middle ground with those who would unflinchingly commit such acts. How could we see eye to eye?

I will bury this terror with the humility of those who are left to deal with the aftermath.

For every one of you there are millions of us.

I may be clutching my children tightly now, but tomorrow the sun will rise.

And you'll be old news.

Deliverance

2013-04-13T15:48:00.001-07:00

I've always kinda envied obstetricians.

I remember with my first child. We laughed at the positive pregnancy test. We went to the doctors visits together. So many milestones: the first heartbeat, the ultrasound, and the kicking. The OB was like a guide walking through a foreign land. She sauntered ahead of us merrily, advising gently but firmly. Of course there were bumps in the road, there always are.

But the end points were knowable. She was not only our doctor, she was a mother herself. And when the time came, she was by our side. We journeyed together, teacher and students. Our eyes bleary at 2:30 in the morning when the pushing, sweating, and clutching were interrupted by the sweet vocalizations of a little boy.

One phase of our lives over, another was about to begin.

***

I also journey with many of my patients. The beginnings, however, are of a more bitter nature. The voyage starts with an incomprehensible diagnosis, a lopsided prognosis. And I, like Charon the ferryman, usher the lonely souls onto my boat. I steer through the uncertain fog, my hands wrapped solidly around the oar. Belting through turbulent waters, the bumps jar even when expected. The sign posts are few and hard to interpret.

I coo soothing words and hold hands, even with the realization that I am of limited experience. No matter how often I make the trip, I only get so close to the opposing shore.

The time eventually comes. We dock. The family and I huddle while the courageous soul leaps out of the boat and onto the other side.

We wave, heartbroken.

Unlike that wondrous morning with my wife and precious child,

there is only silence.

How Long Has It Been Since You Spent Quality Time With Your Doctor?

2013-04-12T09:06:00.001-07:00

I'm going to be a little nondescript here.

The other day I saw a patient in the hospital. I was covering for a partner. The patient was gravely ill. There were many decisions to be made, surgeries to be planned, and antibiotics to be given. Of the fourteen days in the oncology unit, I may have be the rounding doc once or twice.

As the situation worsened, the relationship between the patient, family, and medical staff had begun to decline. Although I assessed the patient and wrote my billable note in the morning, I couldn't help but feel that there was much more to be done. Decisions were being left open ended, and many of the realities of diagnosis and prognosis were ignored like that annoying friend that one never acknowledges in public.

As luck would have it, a number of cancellations in my schedule left my afternoon completely free. So I made a few phone calls and gathered the family. I walked into the room and sat down comfortably on a chair, and looked up at all those anxious faces.

Tell me about it.

I didn't move for nearly two hours. I waited patiently on phone calls, bathroom breaks, and pillow adjustments. When I emerged from the room, the plan was completely different. Surgeries were cancelled, antibiotics stopped, and a modicum of peace was restored to an otherwise hectic situation.

The patient/family didn't need more medical care. They didn't require an xray or a brain scan. They needed an ear to listen, and an experienced voice to help guide them.

This type of interaction takes time. It also saves the healthcare system a boat load of money.

Healthcare reform, meaningful use, quality reporting, etc, etc...what could possibly go wrong?

Well, how long has it been since you spent quality time with your doctor?

Fear Is Like Ice Cream

2013-04-08T19:03:00.000-07:00

My mobile rings at least fifty times a day My pager buzzes double that. I'm stopped in the hall and accosted by doctors, nurses, patients and families. And most of the questions are mundane: an adjustment of the coumadin dose, a formulary change for the antibiotic. Thousands of daily decisions reasoned through years of experience and practice. This is the life of the modern day Internist.

Yet, I can't help but admit that I'm always waiting for the other shoe to drop. Each ring, each buzz, carries the possibility of disaster. Will it be the ER with a hypotensive octogenarian, or the nursing home reporting a patient has been put on a nonrebreathing mask. Or worst of all, a young person with real chest pain and shortness of breath.

I'd be lying if I said it didn't have an affect. Fear, to me, is like ice cream. No matter how often you taste it, you can't help but quiver each time the frozen tundra meets your lips. Unfortunately, the Pavlovian nature of the human conscious can be quite indiscriminate. Sometimes we react to the stimulus in the absence of need. My body jumps awake to the vibrating pager clipped to my waste. I yell into the phone at the poor nurse reporting a skin tear or fall.

This reality can be tiring. The over stimulation of the senses and lack of sleep mean that surprises at the end of the day can be particularly challenging. So when my phone rang this afternoon while waiting for my daughter to finish her ice skating practice, I jerked to attention and fumbled to pick up.

It was Mrs. Morris calling for the third time to inquire about her husband's place on the transplant list. I reflexively began to explain again how, as the internist, I had very little power to dictate how long it would be. But she couldn't wait for my soliloquy to end and cut me short.

Dr. Grumet, Dr Grumet...he got a liver. He just left recovery!

For once, the sound of the other shoe dropping didn't startle me.

It brought me joy.

Heaven And Hell: Portraits Of An Alzheimer's Ward

2013-04-06T08:03:00.000-07:00

The lanky gentleman propels himself forward in a wheel chair towards the nursing station. Crumbles of food fall from his chin and land on his old tattered flannel shirt. He stops, as he is wont to do, at the half door that is controlled by a keypad. He peers over and spies a staff member sitting at the desk in front of an open chart.

I'm hungry, get me some food!

The staff member lifts his head for a moment and returns to his work. If one witnessed this solitary reaction in isolation, it would be assumed that this is a cold and ineffectual haven for the misplaced. But in view of the repetitive nature of this event, it starts to become more clear. This is the fifth request that has been made in the last half hour. The emergency stock of cookies and crackers has already been used up. The wheel chair backs up for a moment and then pushes forward crashing into the door. The series of epithets and racial slurs that follow is enough to make even the most staunch observer blush.

#%#*&#%%%%#!!

A string of panicked words in a foreign language fly out of the mouth of a ancient woman cloistered in a room a few doors away.

Ayudame, ayudame, ayudame, ayudame...ayudame, ayudame, ayudame.

The tone rises and falls. Sometimes the lilt of the voice suggests a question. Others, it's purely a statement of wrath. Occasionally, a moment of silence interjects until the rabble starts over again. It will go on like this all day. So long in fact, that her voice will weaken and become raw. Silence will follow only with the sweet respite of sleep.

Half way down the hall a smallish man sits in a over sized chair placed between doorways. His body limply melts into the cushion, and he weeps uncontrollably. A tall thin Asian woman towers above him draped in over sized pink scrubs. Her cart of medicines has been pushed to the side, and her hands gently reach out to his sorrowful cheeks. She clucks like a mother hen, and gingerly wipes the tears from his eyes.

Oh Harry, Don't cry. Don't cry

Day after day. Year after year.

Only the faces will change.

Brinksmanship

2013-04-04T11:23:00.000-07:00

I hate it when I think of the best retort ten minutes after the conversation has ended...

She had enough. Her son said many times that he didn't want to live this way. Intubated, disfigured with tubes and lines, and riddled with small satellites of cancer throughout his body, he was no longer recognizable. Her voice was unwavering.

Remove the tube.

It was the right decision even though there were signs of improvement. The last vestiges of sepsis had pushed the kidneys into oblivion. The lungs moaned against the ventilator and refused to open. Yet the fever had resolved and the white count was trending back towards normal.

I huddled with the staff and prepared the orders for the morphine and ativan drips. I finished my note and turning the corner, I almost ran smack into the oncologist. She had seen my charting on the EMR, and rushed over to talk to the mother. She was hoping to convince her otherwise. She addressed me before she entered the room.

How come we push people off the building with chemo and then pull away the safety net right as they are hurdling towards the ground and need us the most? Withdraw care? He is just starting to improve!

I was so stunned, I didn't know how to answer. Minutes later the mother shook her head as she listened. She reasoned out loud.

So we pull him from the brink, what then? How are you going to fix the rest?

The oncologist left the room and returned to her clinic, beaten but resigned. The breathing tube would be removed despite her objections.

Sitting in my office moments later, I couldn't help but think the oncologist had it all wrong. Dying from cancer can be like falling off a building. Without interference, one dies instantaneously, no harm no foul. But sometimes we doctors pull out our flimsy tarp at the last minute.

The canvas defies acceleration and hinders death briefly, but doesn't fully cushion the fall. Bones break and vertebrate snap.

The miserable soul then lies prostrate for days on a ventilator in the ICU.

Awaiting the certainty of death,

in the most inglorious fashion.

Healthcare's Dumping Ground?

2013-04-02T13:06:00.002-07:00

I couldn't really blame the social worker. He was just doing his job. The SNF unit connected to the hospital was full of flailing patients. So he thought he would ask for a palliative care consult (after getting an okay from the primary team). It was his third request of the day. He spoke slowly as he tried to untangle the twisted path the patient had taken.

Dr. X was managing poor old failure to thrive before he came to the hospital. But then Dr. Y, the hospitalist, admitted him and treated the urinary tract infection. Dr. Z was covering Dr. W on the cardiology side. And of course Dr. S, the oncologist, was giving chemo before he landed here.

My head started to swirl as I waived him away and ambled back to the nursing station. This was another complex patient with multiple doctors and few answers. I reviewed the chart and then went to the room and began my exam. He was an elderly, confused, chronically ill gentleman with labored breathing. He was unable to communicate effectively.

I left the room and called the daughter. She hadn't spoken to any of the doctors in awhile. She was hoping to meet later in the day to talk. I hung up and paged the nurse practitioner who covered the hospitalist patients in the SNF. Even a move down the hallway ended in a hand off to yet another provider.

It was just as I expected. Doctor X didn't come to the hospital. Dr Y had finished his week as hospitalist and was now off for the next seven days. Dr. Z and Dr. W signed off the case since the cardiomyopathy wasn't responding to maximal therapy. And Dr. S, the oncologist said that the metastatic prostate cancer was the least of the patients problem.

So it would be me, the newly consulted palliative care specialist, who would sit down and talk to the patient's family about end of life and futility. I would start a little morphine, tweak a few medicines, and stop the ativan due to delirium.

I have to admit that it all left a sour taste in my mouth. This is just one example of many. Yes, this is what we are good at, but it also kind of makes me wonder.

Has palliative care become the last bastion of sanity in the dumping ground of today's disjointed and broken healthcare system?

Your Fly Is Open

2013-03-30T16:39:00.000-07:00

There's a good deal of soul searching that takes place in the exam room. I see every flavor of strength and ugliness of the human character, sometimes all in the same person. This strange mix of human suffering and superlative psychodrama have an effect on a guy. After a decade of chasing this calling (and reaching toward a new number in the tens column of my age no less), I spend a certain amount of time trying to decide who I am.

Now, it's fairly easy to dispel of the white night thing from the beginning. Although a doctor, I'm no angel. At times, my patience runs short.  I have had my moments of combativeness with my colleagues and proffered many apologies.  I am human with all the trimmings that come with the scarred irregularity of humanity.

In this, my patients and I are the same.

It's hard enough coming to the doctor's office with one's body broken and diseased.  It takes a small part strength and a large part courage to bare one's emotions to the stranger sitting across the table. How awkward it is to undress and slip on one of those skimpy gowns with the strings that never seem to tie appropriately in the front or back?

There is enough embarrassment. So when a patient is dressed and the counseling is over, if I happen to notice and open fly or a shirt that is sloppily untucked in the back, I mention it. I come right out and say it no matter how my face may flush or how awkward the following silence may be.  In fact, I do this outside the exam room too. Because I would want someone to tell me.

And maybe in this, I have finally found a definition that suites.

Who am I?

I'm the guy who'll tell you your fly is open.

Every time.