Tuesday, April 21, 2015

Google Hangout Interview with John Bennett

John Bennett and I discussed my book this evening on a google hangout.

Sunday, April 19, 2015

Legacy, Some Thoughts On The Death Of Jonathan Crombie

My wife loves Anne of Green Gables.  And every so often she scours Netflix or Amazon Prime looking for the movie to play for the kids.  She is almost always unsuccessful.  Last night, however, she was able to find a version on you tube (with Spanish subtitles none the less).  She popped a bowl of popcorn, and we all settled down to watch this ageless classic.

We were engrossed.  How could you not fall instantly in love with "Anne spelled with an E".  Her hyperbolic and histrionic nature all the more endearing as the plot grows.  Of course, you can't help but like Gilbert also.  At first painted as a bully in his opening scene with Anne, it becomes clear that his jeering words are a school yard ruse to hide his growing affections.

It was around the half way mark that I sadly saw the breaking news on Facebook, Jonathan Crombie (the actor who plays Gilbert) died of a brain hemorrhage.

All the sudden, for me, the story took on greater significance.  Unlike his family and friends, I will never know what kind of man Jonathan Crombie truly was.  Yet his art, his acting, will leave an indelible mark on those of us who grew up with this timeless story.

Of course, it all makes me contemplate legacy.  My father, who died from the same malady at a similar age, left behind a wife and three young boys.  There are also countless patients, physicians, and students who remember his influence thirty five years later.

We all hope that the best parts of ourselves live on long after we have passed.

Legacy is an especially prickly issue for those of us who yearn to create.  The builders, actors, artists, poets, and writers.  For most of us, the act of creation is a lonely and solitary process.  The birth of our "art" is often a complicated and painful labor of love.  We continue day after day, year after year, not for glory or recognition, but because we have to.

That which we produce, the performance we act or the words we write, are the distilled parts of ourselves that we leave for the world.  Long after we are gone and our families have mourned, maybe there will be a little something left.

A word, a phrase, a small bit of wisdom that will find the wayward stranger and bring knowledge, understanding,

or a comforting salve for unhealed wounds.

Tuesday, April 14, 2015

Fixing The Primary Care Crisis by @Drschimpff

The American health care system is in crisis.  Year after year we see prices rise and quality of care spiral downword.  The more money we throw at the problem, the worse things get.  A bevy of politicians, health care consultants, journalists, and even doctors scurry relentlessly for a solution to to this colossal mess.  But, until now, none of them have understood enough to distill the disparate facts into a coherent plan of action.

That all changes with the publication of Dr. Stephen Schimpff's treatise:

Fixing the Primary Care Crisis: Reclaiming the Patient-Doctor Relationship and Returning Healthcare Decisions to You and Your Doctor.  

And I'll take this moment to lob my one and only criticism at the book.  Dr. Schimpff cogently argues that primary care is the linchpin of high-quality, low-cost care.  Thus, in reality, I believe that the title is more aptly "Fixing the Healthcare Crisis".  Anyway....

Never have I read such a concise and soup-to-nuts explanation of what has gone so awry in our current system.  Our lopsided PCP to specialist ratio, coupled with increasing overhead, and poor reimbursements has turned our doctors into referral machines.  The primary care physicians, forced to see in excess of 20 patients a day by an insurance system that under values cognitive medicine, have chosen the path of lease resistance: referrals, diagnostic exams, and procedures.  It's not that they don't want to give stellar care, it's just impossible.

Good, high quality medicine, requires time.  A luxury that is no longer afforded to those MDs who want to keep their doors open and also collect a paycheck.

The solution is less patients, better reimbursement.  Dr Schimpff outlines several ways to achieve this goal including direct practice models, concierge, insurance incentives, and employer based wellness programs.  He tackles current trends including ACO's, Patient Centered Medical Homes, and retail pharmacy clinics.

But most importantly, he defines a path forward to correct our mangled version of healthcare.

It all starts with our primary care physicians.  Give them less patients and more time to think.

I highly suggest you get the longer, more articulate version of these sentiments and buy Dr. Schimpff's book!

Saturday, April 11, 2015

Expiration Date

Everything eventually expires.

I looked down at the bottle of natural spring water in astonishment.  It had an expiration date.  Scanning the empty hospital cafeteria on an early Sunday morning, I wondered what on earth about spring water could go bad?  It had no living parts,  Nothing that serves as nourishment for wayward bacteria or fungus.  The container was sealed.  Pristine.

I figured it was another fiscal hoax, perpetrated on unsuspecting consumers.  You better drink that water fast or you'll have to throw it away and buy a brand new bottle.  I could hear the ka-ching of the cash register as some billionaire somewhere just increased his fortune by a dollar and a quarter.

It was a short two flights of stairs up to the ICU.  Enough for me to contemplate how we so readily believe the little date imprinted on so many of our products.  We throw away perfectly good food.  We dispense of old medications.  There are other things that outlive their usefulness: cleaning products, beauty supplies.

We accept, that for most possessions, there is a natural beginning and end.  Sure we may take that old clunker to the mechanic over and over again.  But eventually it ends up in the junkyard just like every other automobile.  There is only so much that can be fixed.

People, on the other hand, are not allowed such luxury.  We replace the warn out parts when we are able.  We prop up ill and disfigured joints with canes and walkers.  We extirpate nasty cancers and use pills to counter misanthropic metabolisms.

Unlike water, however, we are very alive.

We are faulty.

And no matter how much we refuse to believe,

our time on this earth is finite.

Monday, April 6, 2015

My Review of Becoming Nursey by Kati Kleber (@NurseEyeRoll)

I could never be a nurse.  It's just too hard.  Not only do they have to physically take care of patients (and their body fluids and waste products) but emotionally support said patients, their families, their doctors, and supervise an army of certified nursing aids.  Did I mention that they also must diagnose, manage, and  monitor disease in real time?

It was under these auspices that I came across Becoming Nursey by Katie Kleber while I was working to promote my own book.  I checked her out on twitter (@NurseEyeRoll) and was intrigued enough to jump on Amazon and buy the book.  I was very glad I did.

This is a must read for new nursing graduates, students, and anyone who dreams of entering this sacred profession.  The practical information contained in this book is priceless.  Everything from surviving nursing school, to passing board exams, to organizing your time as a floor nurse is covered.  The text is a clear, organized, and easy to follow set of instructions for tackling day to day challenges.  How I wish I had this type of manual for medical school and residency!

What I think is almost more valuable, however, to not only nurses but also doctors and the community as a whole, is the emotional candor of the book.  Often humorous, sometimes heart-breaking, Kati paints in broad brush strokes the humanity of the profession in general.

We laugh at the descriptions of the physical pitfalls when she describes tackling the not so delicate parts of her job, and we cry when she tells of the emotional hazards we all face while caring for our fellow human beings.

Buy it.

It's a great read!

Monday, March 30, 2015

The ABIM Is Trying to Be relevant; Choose Wisely

The American Board of Internal Medicine is irrelevant.  It has always been.  I realized this when I first certified in Internal Medicine in 2002.  The test was largely fact based and filled with information that I would never need to know in practice.  It did not measure my diagnostic acumen, or my physical exam skills, or my ability to listen and empathize with my patients.

After passing the original test, I forgot mostly about it.  I filed my large diploma sized certificate in a drawer in the back of my office.  You see, I didn't display it prominently because I really didn't care if anyone saw it or not.  It meant nothing.  Not a single patient over ten years asked about my certification status.  It was irrelevant.

A decade into practice I recertified.  This time I was forced to do a number of maintenance of certification activities.  They were time consuming and expensive, but I figured it was the cost of doing business.  I didn't learn anything by participating in these activities.  They didn't help me take better care of my patients, and I didn't exit the process a more informed doctor. It was a waste of time and money.  Irrelevant.

Unfortunately, now the ABIM is trying to be relevant.  Not by creating a superior product or innovating in the continuing education space.  Instead it is foisting a new, sub par, labor-some, and most importantly costly product on its it's physician marketplace.  And it is doing it with the force of governmental mandate (ACA will require board certification as a quality indicator) and tacit support of hospital administrators everywhere (hospitals require board certification for hospital privileges).

This mostly annoying, but previously manageable requirement, has become a thorn in the side of American physicians.

The new MOC is just as irrelevant as the old, it's just a heck of a lot more difficult and expensive to complete.

I feel that it would be overly optimistic to expect the government or the hospital executives to release us from this arduous burden.  In fact, many of us suspect the government cheers on as physicians are forced to close doors and join the big academic or corporate sweat shops.  There is no political will to uncouple the ABIM from healthcare reform.

Hence, we physicians are left with two options.  We can either expose The ABIM as not only irrelevant but also crooked as Dr Wes Fisher has so excellently done.  Maybe this grand foolhardy organization will fall on it's own sword.

Or we can gather together and refuse to certify en mass, and see what happens to hospitals as they try to take away privileges from all their Internal Medicine doctors and specialists.

I think the time has come to make a decision.  Which will we choose?  We better choose wisely.

By the way, happy doctor's day!

Thursday, March 26, 2015

My First Dead Body

I assumed she asked because besides being a hospice volunteer,  I was a medical student and wouldn't get spooked by a dead body.  She probably didn't realize that it was my first week of classes and I hadn't experienced much yet.

She walked into the room with her head slightly bowed forward.  She was physically and emotionally exhausted.  Because of a scheduling snafu, there was only one nurse for the entire hospice floor.  This was her second patient to die that day.

She bayed me to come forward and help prepare the body.  I stared down at the lifeless figure.  I don't remember all the details, but I will never forget the stillness.   It was the first of many occasions where I would marvel at the appalling lack of motion that separates the living from the dead.

We were silent.  When she wanted me to perform some task or another she would point with her fingers.  I think we put an ID tag on the toes.  Maybe we cleaned the body and removed any remaining catheters.  The family had come and gone so there were no cosmetic issues of concern.

And then she took out the bag.  We gently rolled the body over and placed it cleanly underneath.  We pulled out the openings around the torso. Then we tucked in the limbs and head.  Finally she started at the toes and zipped up the bag from the bottom until she came to the face.

She stopped.

For me this was the shell of a man who I had never known.  But for her, for her, he was a breathing, feeling human being.  One whose hand she had held, whose family she had comforted, and whose excrement she had helped clean from his weakened and frail body.  She went to close the zipper but she couldn't.  I put one hand on her shoulder and reached over with the other removing her fingers.

She knelt down in the corner of the room and sobbed as I closed the bag.

Through years of medical education and practice there are many images burned into the depths of my soul.  But when I think of my first experience with a dead body, I don't see a body at all.

I see a nurse.

A humble, grieving, beautiful symbol of all that our profession can be.