Friday, March 16, 2018

i smell smoke

Another random rant:
It’s no wonder we have been hearing more and more about the problem of “burn out” among health care professionals as we witness the premature exodus of capable, dedicated physicians and nurses from a system that defies excellence in patient care by virtue of its unspoken battle cry: Bigger. Faster. Greedier.

Burn out is defined as:
“…a state of physical, emotional, or mental
exhaustion accompanied by
doubts about one’s competence
and the value of one’s work.”
But it doesn’t have as much to do with fatigue as it does with frustration. The problem isn’t about keeping up with technology or advances in diagnostic and treatment modalities. We can do that. The problem is that we are forced to compromise thoroughness in favor of efficiency. Connection in exchange for productivity. Compassion in lieu of profit.
Dedication, fulfillment, and integrity are no longer part of the equation.
When I gave up after thirty years in Family Medicine I told my patients and colleagues I was retiring…when I meant I was quitting. I didn’t put it quite that way, of course. It wasn’t as though I simply got fed up with things, turned in my stethoscope and tongue blades, and slammed the door on my way out of the office. I wasn’t impulsive about it at all. I agonized over the decision for years.

I didn’t leave because of the long hours, or the fact that I’d been running hopelessly behind schedule all day, every day for three decades. I didn’t leave to take an easier position or to make more money. I didn’t ask to be excused because of fatigue or forgetfulness or ill-health.

No. What finally got to me was the erosion of my authority as a physician by self-proclaimed intermediaries who had neither knowledge of nor concern for my patients’ wellbeing. When I started out in medicine the problem was oppressive paperwork; now-a-days it’s an oppositional defiant electronic medical record system. A baffling coding and reimbursement system. The ever-present threat of litigation. A pharmaceutical industry that invests as heavily in marketing as it does in research. A health insurance industry whose number one priority is corporate profit…which translates into seeing more patients faster regardless of the complexity of the presenting problem. I worried I would miss something, and I feared for my patients because of it. It scared me. I had to leave.
“The very concept,
I would say ministerial function of being a physician,
is to be attentive, is to be present,
is to listen to that story,
is to locate the symptoms on the person
of that patient,
not on some screen,
not on some lab result,
but on them."
~Rosmarie Voegth~
It's no wonder we worry about competence given the constraints imposed on our ability to deliver excellent care to our patients. It's no surprise we question the value of our work when we measure it in terms of quality and compassion while the system is busy tallying the receipts. 
Physicians are encouraged to manage their stress…when they are helpless against it. To get outdoors more. To meditate. To eat better and to get more sleep…when, some days, we don’t have time to eat at all. When we can’t break away long enough to poop on the pot. When we don’t have the strength to blink at the end of the day…not because the work has gotten any harder, but because the hoops we have to jump through have multiplied…and somebody in a fancy office is holding them higher.
“America’s healthcare system is neither
healthy, caring, nor a system.”
~Walter Kronkite~
 Looking back on thirty years of practice in the American medical system, I can only say, "It weren't broke." But it sure needs fixin' now.
For more on professional burnout, check out


Sunday, March 4, 2018

this week's challenge

I just registered for the third annual conference on narrative medicine to be held at Kripalu Center for Yoga and Health in July. The title of this conference is "Narrative Medicine--A Cutting-Edge Approach to Healthcare."
Narrative Medicine A Cutting-Edge Approach to Healthcare
·                     July 8–13, 2018
·                     Sunday–Friday: 5 nights
·                     Presenter: Natalie Goldberg
·                     Presenter: Nancy Slonim Aronie
·                     moderator: Lisa Weinert
·                     and more…
For caregivers, doctors, nurses, yoga teachers, writers, and anyone interested in personal narrative as a healing path to recovery.
Now, I don’t know about you, but when I think of cutting edge approaches to health care I think of things like new and more effective antibiotics, high tech scans and digital something-or-others, and robotic microsurgical techniques. But storytelling?? Not so much.
Advances in medicine, whether having to do with the development of new drugs, tests, or methodologies, have to pass rigorous tests of their efficacy and safety before they are introduced into mainstream practice. This requires large scale randomized, double-blind, placebo-controlled studies…which are notoriously difficult to design. Once you have demonstrated the safety and efficacy of, let’s say, a new drug, you still have to consider its cost effectiveness, applicability and acceptance rate. It’s surprising anything makes it through the process. But storytelling??
“I love storytelling.
It’s endlessly healing.”
~Ben Vereen~
For the sake of this discussion, let’s assume that the techniques taught in narrative medicine programs represent an advance in the practice of clinical medicine…that this method improves patient satisfaction, shortens hospital stays, decreases the number of readmissions, and in the long run, saves time and money. The numbers that prove these claims may be hard to get at. How can we measure the effect of patient satisfaction on healing? How would we code and bill for the time it takes to listen to the patient’s real (aka “whole”) story? Won’t it wreak havoc on our schedules to engage with our patients on their terms?
There is one way to find out:
Try it.
See if it works for you. Other people have. Other healthcare providers have reported not only improved patient satisfaction, but an improved sense of personal and professional fulfillment, a greater sense of dedication to and connection with their patients, better insight into the cause and clinical course of the patient’s illness and recovery. More accurate diagnosis. Fewer unnecessary tests. More effective interventions. All of which add up to better health care.
“Each time I told my story,
I lost a bit,
the smallest drop of pain.”
~Alice Sebold~
This is my challenge: look over your patient schedule for the week. Find a day when you have a little built in leeway. Pick a patient who is coming in for the first time. Or for a new problem. Ask this question:
“What do you think I should know
about your situation?”
Then just listen. Try not to interrupt, or redirect, or clarify what the patient says. There will be time for that later. He will tell you everything you need to know…what has happened, how it affects him, how he feels about it, and what he thinks about it. Bam!
This is the technique employed by Rita Charon, director of the Program in Narrative Medicine at Columbia University and chief contributor to the landmark text, The Principles and Practice of Narrative Medicine.
If the concept behind narrative medicine interests you, you might consider ordering a copy. Or…attending this year’s conference!

Friday, February 23, 2018


If you practiced medicine back in the 1970s, you witnessed a dramatic change in the practice of pediatric primary care. By then, advances in medicine had reduced the incidence and toll of many deadly childhood diseases, including infectious diseases (through vaccination, antibiotics and improved hygiene/sanitation), pediatric cancer, asthma, and heart disease. Instead, the emphasis turned toward disease prevention, behavioral pediatrics, and safety. We saw major public health initiatives emphasizing automobile safety (the use of seatbelts and approved car seats for children), prevention of accidental poisoning with the use of child-resistant packaging and safety caps, SIDS prevention, and the use of smoke detectors…all calculated to reduce the incidence of the number one cause of death in childhood: unintentional injuries.
“The safety of the people
shall be the highest law.”
~Marcus Tullius Cicero~

But then, of course, there were still the guns. Headlining the February 2, 2018 issue of Newsweek magazine is this:

“Kids and Guns:
Shooting now the 3rd leading cause of death for US children.”

Which brings me to this true story:

A boy was accompanied to my office by his mother for his well-child exam. I took his past medical history, family history, and social history before examining him. I asked about school, what sports he played, whether or not he wore his seat belt, whether or not there were smoke detectors in the house…routine questions, among others, that covered preventive/safety issues in the home.

Then I asked whether or not there was a gun in the house. Did he know where it was kept and if it was locked and/or loaded? Well, to my surprise, his mother became irate at these questions. It was as if I were accusing her of a crime. Prying into something that was none of my business. As if I was trying to shame her for having a gun in the house. In fact, she was so offended, she wrote a letter to my office manager and left the practice.

Not long afterward, there was a deadly accidental shooting in our community. A young boy died.

~from Townhall
February 20, 2018
Beth Baumann~
This story serves to illustrate the explosive (no pun intended) nature of the gun control debate. No other safety issue has generated such a heated response. This is a concern that all health care providers must confront. It is a huge personal, political, and public health problem. It belongs to all of us.

Wednesday, February 14, 2018

illness, inside and out


Illness can be understood by its impact on the patient both inside and out.

Within, it interrupts normal physiology and function. It alters anatomy. It causes pain. Traditionally, this has been the domain of the healer: diagnosing and treating the illness or injury by asking about symptoms, examining the patient, ordering diagnostic tests, and formulating a plan of treatment. It can all be done at the bedside.
But illness also triggers a cascade of intellectual, emotional, and psychological responses. It affects the patient’s relationships, his capabilities, his expectations, and his role in the family and community. Positive mental and emotional changes have been shown to support the ability to heal. On the other hand, negativity is believed to impede recovery. Unless we take into account the patient’s sense of self when tending to his illness or injury, we may neglect one of the most important determinants of his ability to heal.
“It may take a doctor
to diagnose someone’s illness,
but it takes a friend
to recognize someone’s suffering.”
For example, when the family breadwinner is laid off because of illness, he loses wages. It’s possible he will lose his job. He worries how he will support his family. Fear and uncertainty aggravate the illness. His self-respect and confidence take a punch to the gut. That’s the thing that really hurts. But he won’t tell you about it unless you ask.
“To me the ideal doctor would be a man
endowed with profound knowledge
of life and of the soul,
intuitively divining any suffering
or disorder of whatever kind,
and restoring peace by his mere presence.”
~Henri Amiel~
Or perhaps your patient is a mother with young children at home. Who will take care of them while she is in the hospital? She worries about them. She feels guilty because she can’t be with them. She may actually lie to you in hopes of being discharged from the hospital, denying the pain she still has, or pretending to be stronger than she actually feels. Her narrative is misleading.
The patient’s story extends beyond the bedside. It embraces more than his illness. One person will be crippled by it while another is healed.
We can’t understand a patient’s illness unless we understand how it affects everything around him—his family and friends. His hopes, dreams, and plans for the future. We can’t treat the patient until we hear his whole story.
“The doctor may learn more
about the illness
from the way the patient tells the story
than from the story itself.”
~James B. Herrick~

Sunday, February 4, 2018

we've come a long way


Yesterday—February 3—was National Women Physicians Day. Who knew there was such a thing? This is proof we’ve come a long way since I decided medicine would be my path in life…since the days when women in medicine were regarded with suspicion, disdain, and even mockery.
“If society will not admit
of woman’s free development,
then society must be remodeled.”
~Elizabeth Blackwell~
My journey into the practice of medicine started with my hospitalization for rheumatic fever when I was just three years old. Even at that young age, the experience shaped my sense of self. I never lost my appreciation for the suffering illness creates in a person’s life. I learned to harness the power to heal, and to revere the people who made it possible.
When I was in high school, I volunteered at one of the largest and poorest hospitals in Buffalo, NY. I majored in medical technology in college. I applied to medical school when there was still a 10% quota on women who were admitted—just ten in of a class of one hundred. Today, more women than men go on to study medicine.
“Every woman who heals herself
helps heal all the women
who came before her, and all those
who will come after."
~Dr. Christine Northrup~
I hope that more than just the numbers have changed.
I hope that young women who pursue the study of medicine are openly welcomed into the medical community, mentored, and encouraged to stay with it. I hope they are able to maintain high standards of medical ethics, selflessness, and dedication to patient care. That their male colleagues do not confront them with the disdain, disparagement, and arrogance that sometimes greeted us. That their female colleagues—nurses, therapists, aides, and support staff—feel connected with them in the art and science of patient care.
“The trained nurse has become
one of the great blessings of humanity,
taking a place beside
the physician and the priest.”
~Sir William Osler~
I hope they feel supported by their spouses, children, and friends. That exhaustion doesn’t do them in. That they practice balance in their lives. I wish them enough time and energy to embrace their creative nature, to enjoy their leisure, and to seek spiritual sustenance.
“Wherever the art of medicine is loved,
There is also a love of humanity.”

Sunday, January 28, 2018

variations on a theme

Let’s say you have three patients who are battling cancer.
One is devastated by the diagnosis. She is overwhelmed by fear and dread. Convinced her situation is hopeless, she resists starting chemo. She just wants to die. Her doctor suggests an anti-depressant.
“Once you choose hope,
anything is possible.”
~Christopher Reeve~
One is a man of deep faith. He is convinced that God has the power to cure him even though his prognosis is unfavorable. He devotes himself to prayer and sacrifice because he believes that will earn him God’s mercy. Even when his cancer spreads, he clings to his faith. It gives him hope and a sense of optimism right up until he is forced to surrender to the disease. His doctor tries to be respectful of his faith, but he can’t shake off his own doubts about it.
“Cancer didn’t bring me
to my knees.
It brought me to my feet.”
~Michael Douglas~
The other patient is f***ing pissed off about it. She is not about to lose this battle. After all, she has a husband and children at home. It isn’t fair to them. She agrees to an aggressive plan of treatment that includes surgery, radiation and chemotherapy. She begins a program of exercise, diet, and meditation, and she adopts a practice of loving self-care. She is determined to beat this thing. Her doctor encourages her even though he’s not so sure about self-care, himself.
“You never know how strong you are
until being strong is
the only choice you have.”
~Bob Marley~
Three different patients with the same disease, and three different stories. What difference does it make? There is an abundance of literature concerning the factors that affect a patient’s quality of life during treatment for cancer and how this correlates with his likelihood of recovery. Some factors are immutable: age, gender, and family history, for example. Others are modifiable: emotional and attitudinal factors, dietary factors, level of fitness, faith, and social support.
Given their stories, the physician will approach each of these patients differently, even though each of them has the same fundamental needs: education, encouragement, and support.
When is the last time you had to convince a patient to enter treatment? When is the last time you offered to pray for--or with--a patient?
When is the last time you practiced self-care?
“Self-care is a
divine responsibility.”
~Danielle LaPorte~

Tuesday, January 16, 2018

who we remember and why it matters

I practiced family medicine for over thirty years. I cared for thousands of patients with everything from common colds and itchy rashes, to life-threatening chest pain and end-stage cancer. From birth to death. From morning to night. Like all of you.
As health care providers, we record our patients’ stories. We invade their privacy and probe their bodies. We formulate a differential diagnosis and subject them to sometimes painful testing and treatment. Through it all, we provide encouragement. We embody hope. We offer solace. We confront suffering. We celebrate healing.
“The best way to find yourself
is to lose yourself
in the service of others.”
~Mahatma Gandhi~
It’s no wonder, then, that we carry their stories with us. That, years later, we still remember people we encountered only briefly, not because their stories were particularly gruesome or traumatic or heartbreaking (although many were), nor because their recovery was so extraordinary (sometimes miraculous), but because we took our time with them. We learned from them and we used what they taught us for the rest of our careers. Or, perhaps, we failed them and still can’t forgive ourselves.
Trust me…for any but the most trivial office encounter, patients remember us, too. How we dressed. If our hands were cold. The smell of cigarette smoke on our breath. Whether or not we made eye contact. They read the expression on our faces and our body language. They sensed when we were hurried. They knew if we were listening.
“Give whatever you are doing
and whomever you are with
the gift of your attention.”
~Jim Rohn~
I remember certain patients because I was touched by the suffering they endured, or by the strength they demonstrated, or by wisdom they embraced. I hope they remember me because of the time I spent with them, the compassion I felt, and the knowledge I shared.
Which patients do you remember?
“There is no such thing
as an ordinary human.”
~Stephen Moffat~
How will they remember you?
“I’ve learned that people will forget
what you said,
people will forget what you did,
but people will never forget
how you made them feel.”
~Maya Angelou~