Tag Archives: medicine

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?

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.

Whole Physician Health: Standing at the Precipice

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I published the post below two years ago, and all of it applies even more so today. This week I presented to my department chairs and hospital administration leaders on the importance of addressing physician burnout and well-being. There is a growing sense of urgency around this, some even starting to call it a crisis.

Still, I feel hopeful. Darkest before the dawn, right? Reveal it to heal it, my wise friend says. Physician burnout research has exposed and dissected the problem for 20 years, and now we shift our attention toward solutions.

I will attend the American Conference on Physician Health and the CENTILE Conference next month. I cannot wait to commune with my tribe again, explore and learn, and return to my home institution with tools to build our own program of Whole Physician Health. While we focus on physician health in its own right, we must always remember that it can never be achieved without strong, tight, and fierce connections with all of our fellow caregivers. When we attain this, all of us, especially our patients, are elevated and healed.

Onward, my friends. More to come soon.

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Ever since my presentation to the American College of Surgeons earlier this month on personal resilience in a medical career, I cannot shake the feeling that we need to do more of this work. Physicians from different fields need to talk more to one another, share experiences, and reconnect. We also need to include other members of the care team as equals, and let go the hierarchical thinking that has far outlived its usefulness.

I do not suggest that physicians, nurses, therapists, pharmacists and others should play interchangeable roles in the care of patients. Rather, similar to the central tenet of gender equality, the unique contributions of each team member need to be respected equally for their own merits and importance. As a primary care internist, I must admit that I have seen my professional world through a rather narrow lens until now. I confess that I live at Stage 3, according to David Logan and colleagues’ definition of Tribal Leadership and culture. The mantra for this stage of tribal culture, according to Logan et al, is “I’m great, and you’re not.” Or in my words, “I’m great; you suck.”

“I’m a primary care doctor and I am awesome. I am the true caregiver. I sit with my patients through their hardest life trials, and I know them better than anyone. I am on the front line, I deal with everything! And yet, nobody values me because ‘all’ I do is sit around and think. My work generates only enough money to keep the lights on (what is up with that, anyway?); it’s the surgeons and interventionalists who bring in the big bucks — they are the darlings of the hospital, even though they don’t really know my patients as people…” It’s a bizarre mixture of pride and whining, and any person or group can manifest it.

Earlier this fall, Joy Behar of TV’s “The View” made an offhand comment about Miss Colorado, Kelley Johnson, a nurse, wearing ‘a doctor’s stethoscope,’ during her monologue at the Miss America pageant. We all watched as the media shredded the show and its hosts for apparently degrading nurses. What distressed me most was the nurses vs. doctors war that ensued on social media. Nurses started posting how they, not doctors, are who really care for patients and save lives. Doctors, mostly privately, fumed at the grandiosity and perceived arrogance of these posts. It all boiled down to, “We’re great, they suck. We’re more important, look at us, not them.” The whole situation only served to further fracture an already cracked relationship between doctors and nurses, all because of a few mindless words.

It’s worth considering for a moment, though. Why would nurses get so instantly and violently offended by what was obviously an unscripted, ignorant comment by a daytime talk show host? It cannot be the first time one of them has said something thoughtlessly. What makes any of us react in rage to someone’s unintentional words? It’s usually when the words chafe a raw emotional nerve. “A doctor’s stethoscope.” The implicit accusation here is that nurses are not worthy of using doctors’ instruments. And it triggered such ferocious wrath because so many nurses feel that they are treated this way, that they are seen as inferior, subordinate, unworthy. Internists feel it as compared to surgeons. None would likely ever admit to feeling this way, consciously, at least. But if we are honest with ourselves, we know that we all have that secret gremlin deep inside, who continually questions, no matter how outwardly successful or inwardly confident we may be, whether we are truly worthy to be here. And when someone speaks directly to it, like Joy Behar did, watch out, because that little gremlin will rage, Incredible Hulk-style.

I see so many similarities to the gender debate here. As women, in our conscious minds, we know our worth and our contribution. We know we have an equal right to our roles in civilization. And, at this point in our collective human history, we feel the need to defend those roles, to fight for their visibility and validity. More and more people now recognize that women need men to speak up for gender equality, that it’s not ‘just a women’s issue,’ but rather a human issue, and that all of us will live better, more wholly, when all of us are treated with equal respect and opportunity. The UN’s He for She initiative embodies this ideal.

It’s no different in medicine. At this point in our collective professional history, physician-nurse and other hierarchies still define many of our relationships and operational structures. It’s not all bad, and we have made great progress toward interdisciplinary team care. But the stethoscope firestorm shows that we still have a long way to go. At the CENTILE conference I attended last week, I hate to admit that I was a little surprised and incredulous to see inspiring and groundbreaking research presented by nurses. I have always thought of myself as having the utmost respect for nurses — my mom, my hero, is a nurse. The ICU and inpatient nurses saved me time and again during my intern year, when I had no idea what I was doing. And I depended on them to watch over my patients when I became an attending. But I still harbored an insidious bias that nurses are not scholarly, that they do not (or cannot?) participate in the ‘higher’ academic pursuits of medicine. I stand profoundly humbled, and I am grateful. From now on I will advocate for nurses to participate in academic medicine’s highest activities, seek their contributions in the literature, and voice my support out loud for their important roles in our healthcare system.

We need more conferences like this, more forums in which to share openly all of our strengths and accomplishments. We need to Dream Big Together, to stop comparing and competing, and get in the mud together, to cultivate this vast garden of health and well-being for all. I’ll bring my shovel, you bring your hose, someone else has seeds, another, the soil, and still others, the fertilizer and everything else we will need for the garden to flourish. We all matter, and we all have a unique role to play. Nobody is more important than anyone else, and nobody can do it alone.

We need to take turns leading and following. That is how a cooperative tribe works best. It’s exhausting work, challenging social norms and moving a culture upward. And we simply have to; it’s the right thing to do.