Tuesday, July 22, 2014

Come And Knock On My Door

The house was getting cold.  My wife and kids snuggled in their blankets as I crept out of bed and checked the thermostat.  The subzero winter air howled as a blustery morning took shape outside our windows.   I looked at the digital display with disbelief and manually tapped the screen with my finger, hoping that the jarring motion would loosen the exact faulty screw leading to our frigid state.  No luck.  The thermostat was working just fine.  The problem was much more sinister.  I covered myself with a blanket and ran to the basement.   I paused for a full minute to listen.  Not a peep.  The furnace was absolutely silent.

A few hours and a hefty credit card charge later, a workman strolled into our house.  His bag overflowed with a  gaggle of steel and electronic tools salivating at a chance to sink their jaws into our machinery.  After much tinkering, adjusting electrodes, and forehead scratching, a pronouncement was made.  A few pieces of equipment were procured from the van and adjustments were made.  To our relief, the sweet hum of air passing through vents once again filled our house.  We  sat underneath the counter top, and bathed in the heated air rising from the bowels of the house.

Until, of course, an hour later when a loud clanking sound announced the end of our geyser of contentment.  The temperature plummeted.  Phone calls were made.  And the process started all over again.  Two weeks, various repairmen, and multiple diagnostic tests later, we were no closer to an answer.  The heater would spit and sputter, work for a few hours, and then shut down ominously.

Finally, one of the workers noticed that our air intake valve was pointed in the exact same direction as the exhaust.  Hot air was leaving the exhaust, entering the intake valve, and overheating the system.  It took him seconds to adjust.  The problem never reoccurred.

Years later, as I ponder this cold episode in my families life, I am flabbergasted that a supercomputer didn't exist that could have been hooked up to our furnace and immediately diagnosed the problem.  It appears that heater repairmen are unlikely to be put out of business by the vast expertise of technology.  And they are not alone.

As of this time, no one has created the technology to replace lawyers, accountants, or airline pilots yet either. Sure there is quickbooks, and auto pilot, and legal zoom.  But when push comes to shove, the technology to overthrow these fleshy human beings is just not agile or savvy enough.

Yet time and again, technophiles dream of a world in which Dr. Watson or Dr. Google takes the place of our stethoscoped brethren.  They say that instead of diagnosticians, physicians will be trained to be experts in empathy.  They will be culled from film schools, and broad liberal arts educations.  They will recite poetry instead of treatment plans.

I can't help but think that maybe these oracles, these technologists, need to refocus.  Shouldn't we concentrate on logical systems with finite variables to practice on first?

Figure out how to replace auto mechanics and appliance repairmen.  Then maybe, maybe you should knock on my door.

Monday, July 14, 2014

The Novice

It's a strange thing to be driving about in your car in the middle of the day.  For one who has spent the majority of his professional life sheltered in dark offices and aseptic hospitals, the summer sun and fresh breeze is quite lovely.  One almost begins to approach humanness.  Normal.  This must have been what it felt like before immersion into the tribe of medicine.

Sometimes I have trouble remembering my premedical days.  The divide seems vast.  It is not only the effects of age but an emotional chasm that has formed over the years.  The optimist says I was naive, inexperienced.  The more harsh reality is that I have developed a cynicism, a coarseness which permeates all aspects of life.   I am a person, I am a doctor.  The two mangled halves rarely come together to approach a whole.

But my new reality has begun to unravel the protective coating super glued to my insides.  My clinical encounters are but small punctuations in a day filled en route from location to location.  Homes, hospitals, nursing homes.  I spend more time in the car than anywhere else, and when I am there,  I roll down the windows.  I turn the radio up.  And I am just another guy, speeding down the expressway or caught in traffic.

This feeling like a regular person has had profound affects.  It's helped me look at the world through what seems like an ancient lens: that of a human being first and a doctor second.

I was cruising down a side street the other day when I came to a backup.  I cursed as I slowly progressed through the line of cars.  It took twenty minutes to traverse a single city block.  When I came to the head, I witnessed a macabre scene.  An ambulance was pulled over and a couple of paramedics were performing CPR on a shirtless man on the sidewalk.  His arms were splayed to the side and his chest flailed with each compression.

Within seconds I was moving again, and the the ambulance was barely visible in my rear view mirror.  A lump stuck in my throat and I took a deep breath.  I have watched hundreds of people die, I have performed CPR countless times, but this was somehow different.

For just a moment, I had escaped the curse of all those years of training and experience, and was able to just feel.

I am hoping to carry this with me from patient to patient.  To use all my knowledge and experience to diagnose and treat, but to care for my patients like the uninitiated.

The novice.

Monday, July 7, 2014

We Can Barely Dream In The Place That Empathy Dies

It was a vulnerable time.

The man sitting next to me in the car shifted gently.  His arthritic hands curled into a bow and rested on his lap.  He melted into the seat as if all those years working on automobiles had somehow strangely made him part of one.  I self conscioussly placed the key in the ignition and glided out of the parking spot.  I could feel his gaze upon my shoulder as we both strained to listen.

After the accident, almost the whole body needed to be repaired.  I marveled at the clean finish and drove home overjoyed to forget all that had just happened in the last few weeks.  The shell, however, often betrays that which dwells within.  It only took a few miles before I noticed the knocking coming from somewhere behind the left rear wheel well.

So I drove a few miles with the elderly man from the body repair shop in my passengers seat to see if we could tease out the problem.  I marveled at how uncomfortable I was with this stranger in my personal space.  I was aware of my every movement, my every breath.  For him, this was routine.  How many times had he ridden in the car with a complete stranger trying to diagnose a bump or squeak?  But for me, secretly shattered and struggling with my confidence after an unexpected car accident, my skin bristled with every displacement of the intervening air.

I couldn't help but think of my patients.  Their presence, the exchanging of secrets, the caress of skin, all so familiar.  So familiar for me, the doctor.  The apprenticeship of medicine teaches not only the ad nauseum details of disease but also the physical and emotional closeness.  One learns how to face tragedy not as the event changing moment in another's life, but as a part of ones daily routine.

Yet it occurred to me that sitting in that car, what I most needed at the moment, was to be told that it would all be okay.  The big it (not the knock in the wheel well).   I was so vulnerable.  I needed to be reassured that my confidence would come back, that my heart would stop racing every time I merged onto the highway.  But why would this kindly gentleman know that?  He was just an auto body repair man coming to work, taking a ride to diagnose a problem.  You know, routine.

And I struggle with how to professionally not become the body repair man.  Because indeed cancer, and infections, and heart disease, and death and dying are the fare served up on my daily menu.  My repeated exposure to such things, the nightmares of the general populous, changes how I experience.  Changes how I feel and perceive. The exact qualities that make us master diagnosticians, i.e. repeated exposure, make us lousy human beings.

Those of us steeped in the difficult, have lost the ability to break out of our practiced shell.  We have lost the ability to experience as the novice.  Yet as physicians, it is exactly the novice who we have dedicated our lives and careers to.

It is no wonder there is a disconnect.  Our patients come to us desperately needing our skills and knowledge.  Yet in the process of obtaining these skills, we lose the ability to see the ensuing landscape through the same unaware lens.  We can no longer experience what our patients experience.  Nay, we can barely dream in the place that empathy dies.

The patient is thankful for the help but sometimes just wants to be told that everything will be okay.  The doctor is confused about why physically treating the problem doesn't bring about full resolution.

It turns out we were never able to reproduce the troublesome noise the car made that day.  As I thanked the gentleman for his help, I hung my head sheepishly feeling the weight of yet another humiliation.  He looked me square in the eye, and I could feel the warmth in his grip as he grasped for my hand.

Any time.

His shoulders stooped and his back bent as he walked away.

Any time.

Sunday, June 29, 2014

A House Divided

If you put ten physicians in a room, you will get nine different opinions.  It doesn't matter if you are discussing policy, diagnostics, or politics.  Indeed, medical training develops deep independent thinking. We often feel alone in the care of our patients, we picture ourselves the sole barrier between illness and well being.   We battle our fellow physicians, administrators, and insurers.  You can argue the pros and cons of siloed thinking, but there is no denying the reality of the barriers that we have built around ourselves.  One wonders if a house divided against itself can continue to stand.

There is no doubt that the external threats to the stability of this profession are growing by the minute.  Politicians wrangle to define quality and best practices.  Allied health professions push to expand scope. Lawyers fight to police a group that is reluctant to police itself.  The alphabet soup grows in scary and threatening ways: ACA, ACO, MU, MU2, HCAPS, etc, etc, etc.  As our heads spin in dizzying circles, the physician voice fades into the background.  Nay, it is absent.

We criticize ourselves, we disagree, we reproach our own louder than all those silly little voices that encroach on our freedoms by and by.  This is who we are.  We rarely agree.  In some ways, I believe this is our greatest strength.  We are not afraid of infighting.  

Our own disorderliness, while internally nourishing, proves impotent when faced with external threat.  We are lousy mobilizers.  As much as we fight for our patients, we are poor defenders of ourselves.  

The battle lines have been set, and I believe time grows short.  The window to effect policy will only be open for so long. The practicing clinician, those wading through the mud of actual care, can and must have their voice be heard.  We cannot do this, however, if our words continue to be so glaringly disparate.

A common ground must be illuminated to the masses.  I suspect our failing point in the past was biting off far more than we could chew.  We picked the largest most contentious issues.  It's time we chose a more narrow focus point:

Meaningful use
Maintenance of Certification
Face to Face visits for home health
SGR

I am fairly certain that ninety percent of practicing clinicians (not administrators, health care policy wonks, or non practicing MDs) can agree on these issues.  

They need to be abolished.

Can we find a way to work together on this?

Friday, June 20, 2014

You Create The Cage That Imprisons Your Mind (My response to the comments on my KevinMD post)

I am only going to say this once (my response to the comments on my KevinMD post).

You are far more powerful than you think.

Your hard edges are chiseled in flesh from the molten steel of apprenticeship and add depth, character, and knowledge.  The fibrous scar tissue is experience layered upon experience learned from each searing blow.  Your brow furrows, locked in place by years of leaning over texts, squinting to decipher the tiny letters.

Your stamina is unique.  Tested by years of restless nights, interrupted sleep, and sequential emergencies, your brain reacts with clarity even in the midst of the deepest fog.  Your mind grasps complexities, multifaceted systems, and can bend with riddles and paradox.

You have witnessed both the foibles and strength of the human character.  You are a watcher, a listener,  a confidant.  You walk the tapering line between friend and advisor.  You know more of the spirit than many so called men of God.

You are dexterous.  Your hands glide over the epidermis.  Catheters are inserted, fluid is withdrawn, and diseased organs are extirpated.  Your extremities are just as nimble as your mind.

You may be haunted and broken, but your emotional depths are vast.  You have withstood lifetimes of pain.  Yet you help others find joy in the banal.  You bring hope when the light fades, clarity when there is indecision, and a soothing word to break the silence.

You are no Luddite.  Technology is neither friend nor foe but constant companion.  You adapt.  You learn.

So when I write a blog post declaring "It is time for American physicians to rise up" and you reply that you "hang your head" and that I need to "embrace the despair" I start to believe that you have created the cage that imprisons your own mind.

You are far more powerful than you think.  Do something!

Create a direct pay or concierge practice.
Retire early.
Work for an acute care facility instead of doing primary care.
Become a hospitalist.
Become a consultant and practice on the side.
Talk to each and every patient who will listen to you.
Write a blog, join twitter, yell from the roof of your hospital.
Lobby congress, lobby your fellow docs, lobby your family.

You have more skill, education, and knowledge than you ever will need.

Just flippin do something.  I did.

And then,

then you can complain.

Sunday, June 15, 2014

Is Primary Care Sustainable For Physicians, My Conclusion After A Decade Of Research

I have a confession to make.  The purpose of my last blog post was to set up this one.  What I questioned, at that time, is whether the future of primary care will come from outside change (business, politics, or even specialist physicians and administrators) or internally, hence creative destruction vs internal combustion.

When I entered my first primary care practice in 2002, I had great doubts that the traditional model was sustainable.  So I spent the next 12 years studying.  My field research included stints as a hospitalist, Corp Med doc, private practitioner, and concierge physician.  In the meantime, I became a legal expert, medical director of multiple nursing facilities, took on a job as assistant medical director of hospice and started a palliative care program, and consulted with home health care companies.  Meanwhile I read every white paper, medical economics article, and op ed that I could get my hands on.

Although I have learned many details, I can distill my research into one overwhelming and primary concept.  This secret sauce, I believe, is what will separate the men from the boys, women from the girls.  It is the most basic question that each primary care practice has to ask itself if it wants to survive the slaughter that is surely coming.  But first, a few principles that the reader may or may not agree with.

1)Whether we like it or not, healthcare's pound of flesh is coming from physicians and patients.  That's right, at the end of the day, pharmaceutical companies, insurers, politicians, and administrators will all come out of this catastrophe with healthy bank accounts and bulging pockets.  If you don't believe this, I can't help you.  The Medicare data dump and Obamacare's large out of pocket deductibles are just a  few glaring examples.  I won't go into depth about this subject because it would require a series of blog posts at minimum.

2)The government and insurers primary goal is to cut costs, not improve care.  Said another way, payors may give extra money for innovative models that reduce healthcare costs and produce more healthy patients for short term.  But eventually they will stop.  They want their cake and eat it too.  I don't care if your model creates fifteen percent savings in the future, if it costs the insurers fifteen percent extra up front, it is a zero sum game.  Don't expect their support in the future.

That being said, the litmus test for any current practice model thus has become overhead.

Let me say this again.

If you want to survive today in primary care medicine you must have an extraordinary low practice overhead.

The government will not pay you more.  Insurers will not pay you more (i.e. pound of flesh we talked about previously.)  Patients can afford some concierge and direct pay fees, but don't expect to be able to leverage them either (Because they are getting squeezed by healthcare too).  And the cost of business and compliance will do nothing but go up in the next decade (inflation, meaningful use, technology, rental fees, etc.)

Primary care doctors who have been drowning for years understand this.  They have one of two options.  They either throw their hands up in the air, and join Corp Med for stability (the majority) or they begin an alternative low overhead practice (concierge or direct pay).  And mind you, those PCPs who opt for a new model are generally working very lean.

Non primary care doctors trying to enter this space, I believe, have not benefited from the years of being caught under the wheel.  They opt for high overhead, personnel intensive, high flair practices that truly deliver an awesome product.  But my prediction is that they will die an unfortunate and costly death.  Because, in the end, there is no one to pay for it.  Medicare won't.  The insurers will for a period of time, but not in the end (they want their cake and eat it to).  Patients won't.  Venture capitalists and tech visionaries may in the short term, but eventually they don't like losing money either.

That's why I blended home based practice and nursing home work as the two arms of my new business.  The common thread, of course, is an almost zero overhead.  That is where my experience has led me.

Will change come from outside or from within?

Do you want to know if your practice has there right stuff to survive the turbulent future that primary care faces?  Ask yourself this one question:

How much of every dollar that you make are you paying out to someone else?

Thursday, June 12, 2014

Creative Destruction Or Internal Combustion?

Everyone seems to have a solution for the primary care crisis.  Businessman and venture capitalist Vinod Khosla thinks technology and big data will replace the imperfect physician.  Tony Hsieh and Zubin Damania (x-hospitalist and comedian/rapper) are banking on the direct practice model created by Iora Health.  Politicians, economists, and technologists all chime in with their perspectives.

Below the surface bubbles a provocative and troubling question.  Many of these entrepreneurial "experts" have little previous experience actually running a primary care practice or taking care of the average outpatient.  Although no one has directly said it (except Khosla), the underlying assumption is that change is too big or too important to come from within.  They argue that those immersed in the bubble of inefficient and expensive day to day care must be blinded by their own involvement.  These "leaders" espouse creative destruction and spurn internal combustion.

But I wonder if "good" primary care is something that can be totally grasped from the outside.  My understanding is radically different from what it was before medical school or even in residency.  With experience, my viewpoints have changed, my techniques have evolved, and my awareness has grown.  I couldn't imagine approaching disruptive change without the knowledge I now hold.

So I looked with great enthusiasm to plot the path of Iora Health and internist Rushika Fernandopulle.  What I found, however, was an unsustainable model (Iora health I believe has still never made a profit) heavily dependent on venture capital.  The Atul Gawande New Yorker article talks of a team of two physicians, two nurse practitioners, one social worker, and eight health care coaches taking care of 1200 patients.  Certainly this model is not cost efficient.  In my previous practice, I was overseeing 2000 patients on my own (and yes, my average hospital census was not much higher than theirs).  It seems there was a lot of hype and Internet buzz, but many questions still remain.  Is Iora health still running the Atlantic City clinic?  I couldn't seem to find any information about that on the web.  I would like to know more.

I am an internal medicine physician.  I have been practicing primary care, hospital medicine, and palliative care since 2002.  In January of this year, I started a new and innovative practice in which I visit patients in their homes and in the nursing home.  I schedule a full hour for each outpatient visit and answer my phone personally.

And by the way, so far I can pay my own bills and my admission rate is low.

No venture capital investors, no yoga classes, no health care coaches, no fancy videos or selection of expensive teas in my waiting room.

Instead, I do something much more simple.

I spend a lot of time with each patient.