Tuesday, March 3, 2015

Does Medicare Allow For Agility and Innovation?

The call came around 10 pm on Saturday night. Helen was concerned by her mother’s cough and lethargy. I checked my schedule, and we agreed to meet at the house first thing in the morning. 
I awoke before the sun rose. My car rustled through the half-melted snow as I sped down the freeway. Thirty minutes later, I pulled up to the small bungalow at the end of the street. Helen and her husband greeted me at the door. The look of concern was apparent on both their faces.
We chatted for a few minutes before I went to the bedroom to do my exam. Helen felt her mother was generally doing well at home by herself, but the last few days had been rough. She caught a cough from one of the grandchildren and was slow to recover.  
I knelt at the bedside and examined my patient. She was alert and coherent.  There was a deep rattling sound coming from her left lower lung. Her mucous membranes were moist, but she was weak and resistant to getting out of bed. 
She had pneumonia.

See the rest of my post at The Medical Bag.

Sunday, March 1, 2015

The Wise Man, His Son, and the Camel

There is an ancient parable about a wise man who travels with is son and a camel through the desert on a long journey.  Being wise and kind, he estimates the sweltering heat will take a toll on his steadfast animal and so decides to unburden the beast for a short period.

My daughter is screaming.  She has planted herself on the ground in the middle of a shopping center, and dug her heals in.  She will not move.  After a day of disappointments she has reached her breaking point.  Overwhelmed by the helplessness of being a seven year old, she has decided to take control over the only thing she has left: her body.

My wife and I approach the situation cautiously.  Although our blood is starting to boil, we recognize a pattern of behavior that signals fatigue and probably hunger.  Our compassion is blunted by a repeated pattern that both of us know needs to be broken.  Even if her behavior has an explanation, at some point maladaptive actions need to be redirected into more mature coping skills.

People are starting to stare.

As with any journey of consequence, the wise man and his son encounter fellow travelers from time to time.   The first is a set of merchants, leading a caravan of pack animals lugging their wears from one port of commerce to the next.  They are men of few words but distinct opinions.  They shake their heads at the site of the two humans walking side by side with the camel unhindered by cargo.

"Such a hot day and these fools choose to walk instead of mount their animal"

We sit quietly next to our daughter and whisper calmly into her ears.  Our assuaging words are not having the desired effect.  She disagrees vociferously.  An older couple walking past looks down at us with disgust.  They don't speak, but their eyes say volumes.  They think it is unconscionable that we let our daughter treat us in this way.  In their day, a child only spoke when spoken to.  Adults these days have become so indulgent and have lost control.

My wife and I are all too aware of their opinions.  We feel the disapproval pitter-patter onto our backs like the first drops of what will become a torrential rain.  We try to tune the world out and redirect our attention to our daughter.

The wise man feeling the sting of disapproval  turns to his son and offers him a boost up onto the camel.  His son, already tired from the arduous journey, takes the reigns happily. 

Until they come upon a traveling gaggle of performers.  They are making the journey from one kingdom to the next to perform for some important prince or another.  They are clowns and acrobats, actors and comedians.  

Upon noticing the wise man accompanying his son perched atop the camel they shake their heads disapprovingly.  

"What of respect for one's elders?  The old man wears out his tired legs as his majesty, the spoiled child rides in luxury."

My anger is staring to grow.  We decide to change approaches.  We demand that my daughter get up immediately using our most stern and forceful voices.  She looks up at us and her crying gets even louder. She now is completely unhinged.

A small crowd has started to gather adjacent to one of the store fronts.  We can hear their whispers.  A  growing chorus of voices using distinct words but in hushed tones.  They feel bad for the poor child who is being harangued by her parents.  She needs patience and understanding, not anger.

Again embarrassed by the attention, the wise man switches places with his son and continues the monotonous expedition.  It is many more days before they encounter a group of smugglers brandishing weapons and overfilled casks of wine.

The smugglers appraise the wise man and his son and quickly realize that there is little to plunder or pillage.  They laugh as they pass at the ancient one.  Frail and old, he must rely on his poor son to lead him around on a camel.  

"Old man, old man, one step from the grave, use those wobbly knees while you still can!" they croon as they race by on their trusted steeds.

My wife finally gives up on negotiations and picks up my screaming daughter, and we walk quickly towards the exit.  Young and old see my daughters tears and make sweet comforting faces and wave in her direction.

The wise man jumps off the camel.  He stands beneath the animal, and with a great groan heaves it onto his shoulders.  And they finish their journey in this manner.  

They still encounter other people on the road, from time to time, who have a plethora of opinions.  

But now the passersby are too stunned to open their mouths.

Monday, February 23, 2015

The Wolves Are Licking Their Lips

There is much sacred in the hallowed halls of medicine. As any other secret society, this fraternal order of health care professionals has its own language, costumes, and humor. The pathway from pre-medical student, medical student, resident, and finally to attending is heavily marked with ritual and ever-expanding responsibilities. The world opens and unfolds before the eyes of the novice.
There is no more enduring symbol of membership in this group than the modern-day hospital. For those who don’t belong, only fear and wonder lie behind the sliding glass doors of the entry to the emergency room. For the initiated, however, a highly classified world expands and defines our existence.  
It was in the hospital where I diagnosed my first disease. I led my first team. I saved my first life.

Read the rest of my post at The Medical Bag.

Sunday, February 22, 2015

Burned Out

Walter was far older than his chronological age.  A mere thirteen years, he kept company with a much older crew.  Doctors, nurses, and CNA's were his constant companions.  The other kids on his floor were either too sick to interact, or came and left within a matter of days.  But not Walter.  His heart was too weak to allow his departure, but too strong to be first in line for a transplant.

So he passed his spare time with the staff.  He often duped me and the other medical students out of our pocket change with some confidence game or another.  He was like a younger sibling, or maybe the hospital mascot.  Everybody knew him, and everybody loved him.  Unlike friends and neighbors, however, we knew the most intimate details of his medical history.  We examined his body and ordered blood tests.  We were in charge of his well being.

Walter was the patient I spent the most time with during my medical school career.  He was a constant presence throughout my three months of pediatrics.  The last day of my rotation, the nursing staff got the unexpected call.  Walter was prepped and taken to the operating room.  A child had died tragically, and Walter was given a second chance at life.  Around midnight my team snuck into the ICU and peeled back the curtain.

Walter was alive and well.  A breathing tube snaked from his mouth and chest tubes hung from his bedside.  The grayish pallor of his face had been replaced by a pink glow.  I took one last look back and left the ICU.  And left my pediatrics rotation.

And stepped out of Walter's life forever.

Years later, I am struck by how many times I have repeated this cycle in my medical career.  Patients come and go.  Doctor is inserted at most intense moment.  The patient dies, or leaves the hospital, or exits the nursing home, or moves away.  We live a life of transience.

I used to think of this as intimacy.  As I get older, I question this belief more and more.  For true intimacy, confidence is earned, not given forthright. It is the product of shared struggle and trust.  And when someone you are intimate with dies or leaves your life, there is a period of mourning, a time for closure.

What physicians experience today is feigned intimacy.  We swoop into people's lives during their most intense moments and leave abruptly.

It's no wonder most of us walk the hospital floors with gaping holes in our sides that only we are unable to see.


Gasping for air amongst the charred remains.

Burned out.

(If you liked this post, please check out my newly released book: I Am Your Doctor And This Is My Humble Opinion).

Wednesday, February 18, 2015

What is it like to be your primary care physician? How do day-to-day pressures, concerns and unfolding developments impact the one who looks after your health and wellbeing? What does your doctor feel about the responsibilities and nagging questions that are an integral part of every waking hour? What is it like to know that each routine decision is potentially life-altering to your care? Who cares about your future medical care?  
Jordan Grumet's writing builds an insider's level of understanding. His unique delivery is simple and eloquently succinct. His potential audience is at a critical juncture in medical-political development, particularly in the United States, and his impactful prose is already vitally felt by a growing number of readers. The timing is optimal for Jordan's writing to be published as a widely accessible collection of stories and essays. 
Reverent dedication to quality diagnostic care permeates his writing and motivates Jordan to share from the head and heart. Each new essay challenges his readers to think and feel, taking on the varying perspectives of his challenging, endearing and beloved patients, and of family members of the ill or dying. Jordan's words deepen our understanding of the unwelcome, or sometimes welcome, arrival of Death.  
Jordan opines from experience, while he illustrates doctor-patient relations; doctor-colleague conduct and cooperation; and the impact that exponentially increasing forms, restrictions, technology and time commitment have on the delivery of quality care to patients. You and I and all of those in the medical system feel the impact of this government- and insurance-driven regulatory environment. More and more physicians are shutting down, opting out or simply struggling to juggle the burden of imposed digital and paper requirements, while their expertise is in medicine. Quality medical care, based on face-to-face doctor-patient relationship building, is lagging as a result. Jordan Grumet delivers this news powerfully and persuasively. His ability to do so is both timely and important.  
Married with two children, he sometimes includes family members in descriptions of his daily life and medical practice. In one essay, Jordan relates how his son's birth reawakens a depth of feeling that he previously guarded tightly as protection from the emotional impact of his work. In story after short story, Jordan reveals to us just how he is able to channel a full range of emotions, healthily and consciously, into his daily interactions.  
To whom does Jordan's writing appeal? Doctors, nurses and ancillary support workers all relate strongly to his descriptions of the front lines of medical care. Lay people who care about the future of their own medical needs, and all who've felt the benefits of kindly delivered care, resonate with his words. These various reading audiences either nod knowingly, based on their own similar experiences, or burst into tears as they "get it" that a physician is called to devote such an ample measure of body, heart and soul to their compassionate care.  

Humility. Naked self-assessment. Doubt. Surety. Wonder. Devotion. A peek inside.

Tuesday, February 17, 2015

The New HMO Fiasco

There is no more perverse, more derailed concept in today’s health care environment than fee-for-service. Even Wikipedia knows true evil when it encounters it. Let’s read their definition:

Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Similarly, when patients are shielded from paying (cost-sharing) by health insurance coverage, they are incentivized to welcome any medical service that might do some good. FFS is the dominant physician payment method in the United States,[1] it raises costs, discourages the efficiencies of integrated care, and a variety of reform efforts have been attempted, recommended, or initiated to reduce its influence (such as moving towards bundled payments and capitation). In capitation, physicians are discouraged from performing procedures, including necessary ones, because they are not paid anything extra for performing them.

And yet, year after year, American health care has managed to stay afloat with this supposedly deranged scheme. In fact, provider payments have continued to spiral lower even as the overall cost of caring for our nation has increased dramatically. By most estimates, physician services only account for 10%-15% of annual spending.

Read the rest of my post at The Medical Bag.

Monday, February 16, 2015

When In The Course

As high school teachers go, he was an anomaly.  A rare mix of humor and excitement, he was able to extract from his students the last ounce of concentration left at the end of a busy school day.  He taught my United States history class.  Long after I had collected acceptances from colleges my senior year, I sat engaged and learning a subject I frankly had little interest in.

He was constant energy.  He zoomed about the room, the tempo of his voice nearly as erratic as it's volume.  The attention demanded by his motion was only second to the content of his lecture. He made history both intoxicating and palpable.  A memorizer of theorems, a solver of equations, I struggled to imbibe the spray of knowledge shooting in my direction.

I never studied so hard, and yet looked forward to each and every lesson plan.

One afternoon he walked into the classroom and wordlessly turned on the overhead projector.  I read quickly through the large text on the screen:

When in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.--That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, --That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn, that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security.--Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

It was the first two paragraphs of the declaration of independence.  Our assignment was to memorize the words.  Then we would have five minutes to write the paragraphs by rote memory.  The groans and sputters from the students lasted nearly the whole class.

Each night I sat with paper and pencil.  The first few days were spent memorizing.  My surprise, however, was that speed was also an issue.  Not only did I have to know the material, I had to be able to spew it back on command.  Occasionally my hands would cramp, and I would have to stop for a few minutes and rest.

By the day of the quiz, I must have written those paragraphs hundreds of times.  I and my classmates  finished with just seconds left.  Our teacher dutifully walked up and down the aisles collecting the loose-leaf papers covered with mostly illegible sprawl.  And then he paraded up to the front of the classroom, and with great pomp and circumstance he threw them into the trash.

The collective gasp was interrupted by a particularly brave girl in the front row.  She wanted to know why it was so important to memorize the words when we could look them up.

The teacher smiled wryly and a sparkle flashed across his face:

One day there may no longer be paper, or computers.

We all sat dumbfounded wondering if our beloved teacher had finally fallen of his rocker.

But strangely enough, years later, I still have those words deeply ingrained in my memory.

When in the course of human events... 

Maybe he was trying to teach us that the tyranny of despotism was not something read on paper but carried in one's bosom.  Our forefathers didn't need to memorize words because the fight for freedom and equality was emblazoned on their backs from personal experience.  Generations later, prospering from the battles our ancestors won, my teacher wanted his students to hold these ideas (and words) as dear as those who originally wrote them.

This is our foundation.

I find so many parallels with what is happening in medical education today.  We love to dispense with the old ways in favor of all that is new and shiny.  We are starting to talk of discarding large chunks of medical education as irrelevant.  We have mostly abandoned physical exam skills due to the flexibility and ease of diagnostic testing.

And I see my old teachers standing in font of me as if they were addressing a high school US history class:

What if there were no CT scans?