Eat What You Kill

IMG_6023

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?

No Substitute for Time

DSC_0401

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.

Resistors In Series

Estes 2011

As nerd stuff goes, biology has always been more my speed than physics.  When my group in AP bio got to dissect a fresh frozen elk heart instead of a preserved sheep heart, I was positively overjoyed.  I remember so clearly the size (almost as big as my head) and weight of it, the texture of the muscle.  I can still see the valves, the heartstrings, and coagulated blood in the right and left atria.  So it kind of surprised me when I thought of a physics metaphor for our politics today.  I, the daughter of a PhD in applied mechanics, earned the lowest grade of my college career in first quarter physics.

Like many science nerd adolescents of the 80’s, I looked forward to new episodes of “MacGyver” every week.  The handsome, mullet-sporting Richard Dean Anderson always jerry-rigged his way out of life-threatening situations using everyday chemistry and such.  How fun that my kids can now enjoy the same drama with the CBS “MacGyver” reboot, starring Lucas Till.  We bond over TV, my kids and I.

macgyver white board

In the “Chisel” episode, Mac and his team find themselves barricaded inside a US Embassy, under attack by terrorists.  On a white board, he calculates how many inches of paper to place in front of the windows to stop incoming machine gun bullets—it’s 8 in this case.  [As an aside, the Mythbusters showed that paper is a plausible form of body armor.]  This got me thinking: one sheet of paper, so thin and flimsy, is easily shredded.  But layered in redundance, it can stop a barrage of deadly bullets.  It feels a lot like our national political activism since last November.

Women, scientists, environmentalists, educators, people of color, the LGBTQ community, Native Americans, writers, actors, physicians, patients, religious groups, law enforcement, legislators, and the press—We have all found our legs and our voices; we have stood and proclaimed not only our opposition to 45, but our commitment to our core values of inclusion, equality, respect for the planet, and respect for one another.  I submit that we are resistors in series.

resistors in seriesYou may recall from physics class that when resistors are placed end to end in an electrical circuit, their total resistance is the sum of their individual impedance units.  As the current passes through one resistor, it encounters the next one, and the next, one after another, slowing its progress.  I like to see today’s activist groups in this way, each contributing several layers to the dense, thick paper barricade at the windows of democracy as we know it, defending it against attack.  And the more we can stand united, supporting one another, the stronger we will be.  Could our resistance even be exponential, rather than simply additive?

Tyrants and authoritarians divide to conquer–they like resistors in parallel, where the total impedance is actually a fraction of each individual unit’s resistance.  By pitting each group against every other, a despot can trample them each/all with ease, and they might never see it coming—the same voltage directed across multiple, isolated resistors transforms them into conductors of the oppressor’s will.resistors in parallel

Perhaps this was our orientation prior to the last election.  We each had our pet causes, for which we felt varying degrees of personal activism.  We saw ourselves as detached, benignly unconnected.  But as we have witnessed a progressive threat marching against everything that we care about, a shared, collective threat, a new current has sparked.  Perhaps this mutual unease has reorganized us to connect in succession, to close ranks.

I was reminded of this idea when I read this piece by Charles M. Blow in the New York Times.  He posits that “America regularly experiences bouts of regression, but fortunately, it is in those regressive periods that some of our greatest movements and greatest voices… found their footing.”  Then I came across another article from The Atlantic, suggesting that even our legislators may be reorienting themselves into more serial, additive connectedness:

In hindsight, the Democrats’ decision to not allow partisanship to subsume collegiality or compassion, to cheer McCain along with their Republican colleagues, to embrace a friend even as he cast a decisive vote to move forward with a bill they despised, no longer seems naive. “I hope we can again rely on humility, on our need to cooperate, on our dependence on each other to learn how to trust each other again and by so doing better serve the people who elected us,” McCain had said in his speech.  

Had Democrats met that vote by attacking McCain, he might not have voted no [on the Senate’s ‘skinny repeal’ of the Affordable Care Act] last night. He might not have been so immune to the entreaties of his colleagues. He might not have resisted the arm-twisting of the president who never spent a day in public service before winning an election, who mocked him so cruelly two years ago. He might have decided against casting a vote to derail his own party’s seven-year crusade to dismantle the Affordable Care Act, a goal he still endorses.

I know my analogy vastly oversimplifies our political landscape.  Still, it comforts me.  I feel particularly focused on healthcare today, and I like to think that even if healthcare is not someone else’s chief concern, she will stand up with me when our healthcare system is under attack, just like I will rise with her in defense of our natural treasures, etc.  We stand, shoulder to shoulder, hand in hand, to resist and defend.  This vision of unity and cohesion is my hope and aspiration, not just now, but for generations to come.