Category Archives: NaBloPoMo

Eat What You Kill

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NaBloPoMo 2017: Field Notes from a Life in Medicine

Sounds like a mantra from a survival reality show, right?  Akin to “Eat or be Eaten,” “Kill or Be Killed.”  It’s also a common reference to the prevailing business model in our American scarcity-minded, competition-driven, fee-for-service healthcare culture.  How ironic, the application of these words to this profession.  It was explained to me essentially as, “Every man for himself, and you’re a minion.  You are expected to be ‘productive’ in this business to justify your compensation and contribute to the bottom line.  We measure productivity by number of patients seen and accompanying collections.  Pull your own weight or there will be consequences.”

Of course, from a capitalist business standpoint, this makes sense.  I provide a service that others require.  I should offer it widely, accommodate customer expectations and demands, expand my suite of offerings early and often, and charge for everything.  The more I can get customers to consume and pay, the better off my business.  I have a fundamental problem with this approach when the practice of medicine focuses on business first and patient care second.  Nobody admits to this attitude, of course it’s about patients first, everybody says.  Then my colleague makes a suggestion for patient care improvement, or I express concern about conveyor belt medicine burning doctors out.  Inevitably, the primary response from leadership is something along the lines of ‘that costs too much,’ and ‘that’s the only way to keep the lights on.’  I understand the math.  I despise the premise.

Medicine and healthcare delivery should always transcend the detached, transactional, and ruthless nature of the free market.  Chris Ladd, a conservative thinker and writer, describes this idea eloquently here.  It occurred to me today, replying to Stacey Holley’s comment on my post about spending time with patients, that even those who profit from our flawed American system are also terminally distressed by it.  Insurers, hospitals, pharmaceutical companies and their executives live in a constant state of fight-or-flight defensive posturing, fearing for their livelihoods in market share, revenue, solvency, and survival.  How tragically ironic.

Personally, I have difficulty envisioning a single-payer, government run healthcare program as the primary delivery system in the United States.  Our culture is simply far too individualistic, too fundamentally ingrained with ‘every man for himself.’  However, I think we can still work with the concept of universal healthcare, wherein all people have access to basic preventive and catastrophic care, regardless of income or status, without risk of bankruptcy.  A strong argument can be made that the only entity who could or should be truly invested in the health and well-being of all of us, throughout our lifespan, is our government, particularly in the realms of prevention and health maintenance.  We just need to loosen our societal grip on ‘that’s just how it works,’ and ‘I need to get mine,’ and allow ourselves to be led more by our collaborative, altruistic, and humanitarian leanings.  In my experience, diverse groups of intelligent and energetic people, working toward ambitious and aspirational goals, generate synergy.  This kind of cooperation fosters passion, joy, inspired creativity,  and magnificent innovation.  Who knows what novel solutions we may invent, if we only put down our spears and work together?  And isn’t that the hallmark of American ingenuity?

Medicine and health should be a heartening, collaborative, communal effort wherein we all do our best to help ourselves and each other reach our highest potential.  We are better than our current system, in which truly everybody suffers more than necessary.  I refuse to accept ‘Eat What You Kill’ as any kind of descriptor for my work or that of my colleagues.  We can do better, imagine and create more for ourselves and one another, than this primitive notion.  I know there’s a healthier mantra inside me somewhere…

What can you think of?

What If I Slip?

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NaBloPoMo 2017: Field Notes From a Life in Medicine

40 hours out from my non-traumatic, sports-induced knee collapse, I’m off crutches, woo-hoooooo!  The knee is still swollen and stiff, and people still look twice when they see me limping.  I’m thinking of ordering from Peapod–the thought of walking around the grocery store, which I normally love doing, makes me wince a little.

I’m much more afraid, though, of the back slide that may ensue in these next days and weeks.  I’ve worked so hard the last few years, establishing and entraining an excellent exercise habit, and I was just hitting a period of new growth and ability, so exciting!  I was getting lighter and nimbler on my feet, and now I lurch clumsily, Trandelenburg-like (not really, but kinda).  All year I have felt sluggish and tense if more than two days went by without a work out.  I barely moved yesterday and I loved it, which scares me.

The last few months also saw a shift in my eating, recapturing a sense of control.  I was eating less without hunger or feeling deprived, and though my weight had remained roughly the same, my figure was noticeably streamlining.  I liked looking in the mirror again.  Last night I found myself grazing steadily after dark.  …Stress eating sucks.  I only recognized a few years ago that I do it, and I have since had much more empathy for my patients with similar patterns of food, tobacco, alcohol, and other ‘substance’ use.  I know I should not be shoveling tortilla chips, ice cream, cookies, and candy in my mouth at 10pm.  I know I don’t need the calories, I’m not really hungry, and I will feel guilty on the other side.  And I do it anyway.  It comes in cycles, and I have yet to find a healthier behavioral alternative in those moments (drink a full glass of water, get on the elliptical, drop and 20 push-ups!  Ooo, that last one might work…).

The point is, I really worry how this setback with my knee will derail and reverse all that I have accomplished until now.  (hyperventilation) GAAAAAHH!!

But wait, the injury was less than two days ago…  And I continue to feel better, regaining range of motion and limping slightly less with the help of ibuprofen and RICEing.  What did I write the other night about resting and recovering?  And what I have been preaching to patients about mindfulness, radical acceptance, and doing what you can at the time?  About small change steps sustained over time, and about how worry is counterproductive, because to paraphrase Michael J. Fox, if what you’re worried about actually happens, now you’ve lived it twice!?

Okay, I’ got this.  Plenty of movement I can still do with a bum knee (including maybe push-ups when I feel a late-night ice cream hankering).  I’m still the same motivated workout beast I was 60 hours ago, the same person who just got through a 30 day food challenge with only minor transgressions.  And JEEZ, it’s only been 40 hours.

Well thanks for helping me work through that, my friends.  I’m good now.

No Substitute for Time

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NaBloPoMo 2017: Field Notes From a Life in Medicine

Day 3

How much time do you spend with your doctor each time you see them?  Is it enough?  If they had more time to spend with you, how would you use it?  Would it be better?

I’m too tired and it’s too late tonight to discuss the myriad factors that erode the patient-physician relationship, and thus our medical system in general.  But time comes to mind often for me, and I wonder if patients are as frustrated about it as I am.

Where I work now, I pretty much have as much time as I want with people.  It’s a sweet gig.  I can ask them about their work, their families, their interests.  I have time to listen to the answers, and even connect those with my observations about their health.  The most interesting parts of my interviews are the social history.  What do they spend their days doing at work?  What problems do they solve, who do they interact with, and what brings them meaning at the place where they spend the majority of waking weekday hours?  Then what do they do for fun, what’s life like outside of work?  I get to know my patients as individual, whole people, which I love, and that makes me look forward to every day at work with joy.

But time is not just good for me, for my professional fulfillment.   It’s good for patients, too.  When I spend time asking the important questions, putting together pieces of a person’s symptom puzzle, and do a directed exam, I’m more likely to come to a correct diagnosis and make an appropriate and specific care plan.  When I take the time to explain my rationale, decision process, and possible outcomes and follow up, my patients are more likely to feel seen, heard, and reassured.  They are more likely to stick with the plan and contact me if things change.  The next time they need help, they are more likely to call me and we have another chance to know each other better.

When the physician-patient relationship flourishes, we’re all healthier.

I love this article on The Health Care Blog, which essentially validates the time I take to talk to my patients.  My favorite line:  “More information about the value of a physician-patient encounter will always be found in the content of their communication than in what they ultimately do. The difference in… physicians’ behaviors will not be found in any database, electronic medical record, or machine-learning algorithm. I have yet to see data on the contextual information from a history of the present illness in any data set or quality improvement initiative.”

You may also be interested in this article, describing the origin of the 15 minute clinic visit, and why it really doesn’t make sense.

What do you think about physicians and patients advocating together to change this aspect of our flawed medical system? I know it’s complicated, requiring a hard look at our billing and compensation processes, as well as our productivity-driven, fee-for-service medical culture.  I still think it’s worth pursuing.  There is no substitute for time.  We must protect and defend it; our health depends on it.